SIU Medical & Behavioral Health Coder & Fraud Investigator

CVS Health Corporation; Santa Fe (NM); On-site; USD 44,000 - 94,000; Full time

Benefits offered by this job

Competitive benefits

Bonus potential

Paid time off

Job summary

CVS Health Corporation is seeking a Certified Professional Coder (CPC) for the Special Investigations Unit. The role conducts medical claim reviews to ensure proper CPT/HCPCS coding and documentation alignment.

Requires 3+ years of professional coding, CPC certification, knowledge of CPT/HCPCS, CMS 1500/UB04, and audit experience. Travel as needed; MS Excel/Word proficiency is expected.

Qualifications

• The candidate must hold AAPC CPC certification and have 3+ years of medical/behavioral health coding experience.
• Experience with CPT, HCPCS, Revenue Codes, CMS 1500 and UB04 data elements is required.
• Ability to interpret and apply coding policies and guidelines consistently.
• Experience with Microsoft Excel and Word; ability to travel as needed.

Responsibilities

• Conduct comprehensive medical record reviews to verify codes and modifiers match documentation.
• Provide detailed written summaries of review findings.
• Articulate findings to investigators, leadership, regulators and providers.
• Apply state or CMS guidelines to reviews with minimal support.
• Review cases with Medical Directors to validate decisions.
• Assist with coding questions, state and federal policy investigations.
• Identify potential billing errors, abuse, and fraud; suggest savings opportunities.
• Maintain records and follow workflows to meet metrics.
• Keep up-to-date coding knowledge with changes in compliance and reimbursement.

Skills

CPC coding

Medical coding

CPT/HCPCS knowledge

Documentation auditing

MS Excel

MS Word

Travel ability

Education

AAPC CPC Certification

GED or High School diploma

Tools

Excel

Word

Job description

CVS Health Corporation is seeking a Certified Professional Coder (CPC) for the Special Investigations Unit. The role conducts medical claim reviews to ensure proper CPT/HCPCS coding and documentation alignment.

Requires 3+ years of professional coding, CPC certification, knowledge of CPT/HCPCS, CMS 1500/UB04, and audit experience. Travel as needed; MS Excel/Word proficiency is expected.