Senior Coding Quality Analyst - Claims Integrity & SIU

CVS Health; Minnesota; On-site; USD 47,000 - 102,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Retirement savings options

Paid time off

Job summary

CVS Health is seeking a Senior Coding Quality Analyst (CPC) for the Special Investigations Unit to conduct comprehensive quality reviews of medical coding decisions and ensure adherence to CPT/HCPCS/ICD-10 guidelines across diverse healthcare claims. The role requires 1+ year in coding quality and experience with fraud, waste, abuse, or error surveillance.

Responsibilities include analyzing data, mentoring coders, researching payer-specific guidelines, and identifying process improvements.

Qualifications

• 1+ year of reviewing coding consultant decisions for quality purposes.
• 1+ year of developing and implementing quality remediation plans.
• 1+ year of experience in medical coding in a Fraud, Waste, Abuse and/or error department.
• Knowledge of CPT, HCPCS, ICD-10 and coding guidelines.
• Experience with researching coding and policies.
• Proficiency with Microsoft Excel and Word.

Responsibilities

• Conduct comprehensive quality reviews of completed medical coding reviews to ensure coding logic aligns with medical record documentation, CPT/HCPCS/ICD 10 guidelines, and payer, state, and federal requirements.
• Perform in depth medical record reviews across medical, behavioral health, transportation, and other healthcare provider claims.
• Analyze data, documentation, and evidence to identify potential billing errors, abuse, or fraudulent activity, including concerning billing patterns and trends.
• Handle complex coding reviews, including those related to legal, compliance, escalations, audits, and rework initiatives, resolving issues with sensitivity and professionalism.
• Independently research and apply state, CMS, and payer specific guidelines relevant to audits and reviews.
• Identify opportunities for process improvements, cost savings, and cases that may warrant prepayment review.
• Maintain accurate documentation, records, files, and tracking logs while meeting established deadlines and performance metrics.
• Regularly use departmental tools and workflows with minimal assistance to support daily operations.
• Provide mentorship and training to coders, offering guidance on coding quality, documentation standards, and review methodology.
• Serve as management back up and support team operations in the manager’s absence.
• Maintain up to date knowledge of coding standards, compliance changes, reimbursement methodologies, and investigatory best practices.

Skills

Attention to detail

Analytical thinking

Data interpretation

Education

GED or High School diploma

Tools

Excel

Word

Job description

CVS Health is seeking a Senior Coding Quality Analyst (CPC) for the Special Investigations Unit to conduct comprehensive quality reviews of medical coding decisions and ensure adherence to CPT/HCPCS/ICD-10 guidelines across diverse healthcare claims. The role requires 1+ year in coding quality and experience with fraud, waste, abuse, or error surveillance.

Responsibilities include analyzing data, mentoring coders, researching payer-specific guidelines, and identifying process improvements.