Senior Coding Quality Analyst (CPC) – Special Investigations Unit (Aetna SIU)

CVS Health Corporation; United States; Teletrabalho; USD 85 000 - 120 000; Tempo integral

Resumo da oferta

CVS Health Corporation is seeking a Senior Coding Quality Analyst (CPC) for the Special Investigations Unit to review medical claims and ensure coding accuracy across medical, behavioral health, and related services.

The role requires applying state and payer guidelines, detecting billing irregularities, and documenting findings for leadership. You will mentor coders and support auditing initiatives while maintaining compliance and quality standards.

Qualificações

• AAPC CPC certification required.
• 1+ year of reviewing coding consultant decisions for quality purposes.

Responsabilidades

• Perform comprehensive quality reviews of medical coding to ensure alignment with documentation and CPT/HCPCS/ICD-10 guidelines.
• Conduct in-depth medical record reviews across medical, behavioral health, transportation and other provider claims.
• Analyze data to identify potential billing errors, abuse or fraud and report findings.
• Prepare detailed written summaries of findings and present conclusions to leadership.
• Mentor coders on coding quality, documentation standards and review methodology.

Conhecimentos

Coding quality

Quality reviews

Data analysis

Mentorship

Formação académica

AAPC CPC certification

Descrição da oferta de emprego

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselvesaccountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary

The Senior Coding Quality Analyst (CPC) – Special Investigations Unit will perform medical claim reviews for the Special Investigations Unit (SIU) to ensure compliance with coding practices through a comprehensive record review for medical, behavioral, transportation and other healthcare providers. The CPC must have the ability to determine correct coding and appropriate documentation during the review of medical records. The CPC must also ensure that the state, federal and company requirements are met and recognize any concerning billing patterns or trends.

Activities include:

• 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.
• Prepare detailed written summaries of findings and clearly articulate conclusions to leadership.
• 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.
• Encourage innovative approaches to operational challenges and contribute to continuous improvement of investigative methodologies, tools, and processes.
• Maintains up-to-date coding knowledge, including new changes to coding compliance and reimbursement.

Required Qualifications

• AAPC CPC certification
• 1+ year of reviewing coding consultant decisions for quality purposes