Program Integrity Auditor: Health Plan Coding & Compliance

Sacbar; California, Northern (MO, KY); Hybrid; USD 47,000 - 122,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Job summary

CVS Health is seeking a Program Integrity Auditor to review medical, behavioral, transportation, and other provider records for correct coding and documentation across Medicaid lines of business. The auditor will identify issues and recommend actions to educate providers and recover funds.

Candidates need 3–5 years in claims data review and coding, plus active CPC/CCS/CPMA certification. This full-time role is based in alignment with Arizona time zones and duties as described.

Qualifications

• 3-5 years reviewing claims data and medical records.
• 3-5 years coding with CPT, HCPCS, ICD-10.
• Willing to work Monday-Friday 8am-5pm Arizona Time.
• Active CPC, CCS, or CPMA license.

Responsibilities

• Audit records across Medicaid lines of business to ensure compliant coding and documentation.
• Coordinate audit documentation and reports for review by internal/external staff.
• Identify aberrant billing patterns and potential FWA and report findings.
• Assist with development and implementation of FWA avoidance and detection plans.
• Provide training on regulatory requirements and coding rules.

Skills

Auditing

Claims review

Coding guidelines

Regulatory knowledge

Education

Associate degree

Tools

QuickBase

Job description

CVS Health is seeking a Program Integrity Auditor to review medical, behavioral, transportation, and other provider records for correct coding and documentation across Medicaid lines of business. The auditor will identify issues and recommend actions to educate providers and recover funds.

Candidates need 3–5 years in claims data review and coding, plus active CPC/CCS/CPMA certification. This full-time role is based in alignment with Arizona time zones and duties as described.