Medical Coding Auditor – Compliance & Fraud Review

Hispanic Alliance for Career Enhancement; Wyoming (OH); Hybrid; USD 43,888 - 93,574; Full time

Job summary

CVS Health is seeking a Certified Professional Coder (CPC) to perform medical claim reviews for the Special Investigations Unit (SIU). The role ensures coding accuracy and proper documentation across medical records, behavioral health, transportation and other services.

You will audit records, provide detailed findings, and present results to investigators and leadership. Stay current with CPT/ICD-10 guidelines to detect errors, fraud, and savings opportunities.

Qualifications

• AAPC Certified Professional Coder Certification (CPC).
• 3+ years of experience in medical coding or documentation auditing.
• Knowledge of CPT, HCPCS, ICD-10, CMS 1500 and UB04 data elements.
• Experience with researching coding and policies.
• Experience with Microsoft products, specifically Excel and Word.

Responsibilities

• Conduct comprehensive medical record audits to ensure billed CPT/HCPCS or modifiers match documentation.
• Provide detailed written summaries of coding review findings.
• Articulate findings to investigators, Medicaid leadership, and regulators.
• Research state and CMS guidelines related to audits with minimal support.
• Review and discuss cases with Medical Directors to validate decisions.
• Assist with investigative research related to coding questions and policies.
• Identify potential billing errors, abuse or fraud and opportunities for savings.
• Maintain records and follow workflows to meet metrics and stay up-to-date with coding knowledge.

Skills

AAPC CPC Certification

3+ years medical coding

CPT/HCPCS/ICD-10 knowledge

Policy research

Education

GED or equivalent

AAPC CPC Certification

Tools

Microsoft Excel

Microsoft Word

Job description

CVS Health is seeking a Certified Professional Coder (CPC) to perform medical claim reviews for the Special Investigations Unit (SIU). The role ensures coding accuracy and proper documentation across medical records, behavioral health, transportation and other services.

You will audit records, provide detailed findings, and present results to investigators and leadership. Stay current with CPT/ICD-10 guidelines to detect errors, fraud, and savings opportunities.