SIU Health Coding & Fraud Detection Analyst

Pennsylvania Psychological Association; Raleigh (NC); Hybrid; USD 44,000 - 94,000; Full time

Job summary

CVS Health is seeking a Certified Professional Coder (CPC) to perform medical claim reviews for the Special Investigations Unit, ensuring coding practices align with documentation and CMS/state requirements.

You will review CPT/HCPCS/Revenue Codes, provide detailed findings, and communicate results to investigators, leadership, and providers. Travel may be required; strong attention to detail and compliance are essential.

Qualifications

• Requires AAPC CPC certification and 3+ years of medical and/or behavioral health coding experience, including record review and auditing.
• Proficient in CPT, HCPCS, Revenue Codes; familiar with CMS 1500 and UB04 data elements.
• Demonstrated ability to interpret and apply coding policies and guidelines; proficient with Microsoft Office (Excel, Word).
• Must be able to travel for the role, if needed.

Responsibilities

• Conduct comprehensive medical record review to ensure codes align with documentation.
• Provide detailed written summaries of findings for investigators and stakeholders.
• Articulate findings to investigators, leadership, law enforcement, legal counsel, providers, and regulators.
• Identify potential billing errors, abuse, and fraud; suggest opportunities for savings and prepayment review.
• Maintain records and adhere to workflow processes to meet metrics.

Skills

Attention to detail

Verbal communication

Travel ability

Education

AAPC CPC certification

GED or High School diploma

Tools

Excel

Word

Job description

CVS Health is seeking a Certified Professional Coder (CPC) to perform medical claim reviews for the Special Investigations Unit, ensuring coding practices align with documentation and CMS/state requirements.

You will review CPT/HCPCS/Revenue Codes, provide detailed findings, and communicate results to investigators, leadership, and providers. Travel may be required; strong attention to detail and compliance are essential.