SIU Medical & Behavioral Health Coding Analyst

Preferra Insurance; Augusta (ME); Híbrido; USD 44.000 - 94.000; Jornada completa

Descripción de la vacante

CVS Health is seeking a Certified Professional Coder to join our Special Investigations Unit (SIU). The CPC will perform medical claim reviews across medical, behavioral health, transportation and related services to ensure coding accuracy.

You will produce detailed summaries, discuss findings with investigators and leaders, apply CMS guidelines, and help detect errors, abuse and potential fraud while maintaining thorough records and meeting performance metrics.

Formación

• AAPC CPC certification and 3+ years of coding experience.
• Experience with CPT, HCPCS, Revenue Codes and CMS 1500/UB04.
• Strong ability to interpret and apply coding policies and guidelines.
• Proficiency with Excel and Word.
• Willingness to travel if needed.

Responsabilidades

• Conduct comprehensive medical record reviews to ensure CPT/HCPCS/Revenue code accuracy.
• Provide detailed written summaries of findings.
• Articulate findings to investigators, leadership, regulators, and providers.
• Research state or CMS guidelines related to reviews with minimal support.
• Identify potential billing errors, abuse, and fraud; suggest savings opportunities.
• Maintain thorough records and meet performance metrics.

Conocimientos

CPC certification

Medical record review

Documentation auditing

CPT, HCPCS, Revenue Codes

CMS guidelines

MS Excel

MS Word

Travel willingness

Educación

AAPC CPC certification

GED or high school diploma

Herramientas

Microsoft Excel

Microsoft Word

Descripción del empleo

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 ourselves accountable 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.

The Certified Professional Coder (CPC) 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.

• Conduct a comprehensive medical record review to ensure the CPT/HCPCS/Revenue codes and/or modifiers billed are consistent with medical record documentation.
• Provide detailed written summary of medical record review findings.
• Must be able to articulate findings to investigators, plan leadership, law enforcement, legal counsel, providers, state regulators, etc.
• Research and accurately apply state or CMS guidelines related to the review with minimal support.
• Review and discuss cases with Medical Directors to validate decisions.
• Assist with investigative research related to coding questions, state and federal policies.
• Identify potential billing errors, abuse, and fraud.
• Identify opportunities for savings related to potential cases which may warrant a prepayment review.
• Maintain appropriate records, files, documentation, etc.
• Uses department resources regularly and follows workflows with minimal assistance or intervention to perform daily work to meet metrics.

Maintains up-to-date coding knowledge, including new changes to coding compliance and reimbursement.

Required Qualifications

• AAPC CPC certification
• Minimum of 3 years of experience in medical and/or behavioral health professional coding, with at least 1-2 years of current professional coding experience, including medical record review and documentation auditing.
• Knowledge of professional medical coding systems, including CPT, HCPCS, and Revenue Codes.
• CMS 1500 and UB04 data elements.
• Demonstrated ability to interpret, apply, and consistently apply established coding policies and guidelines.
• Experience with Microsoft products; Excel and Word.
• Ability to travel for the role, if needed.

Preferred Qualifications

• CPMA certification
• Credentials such as certification from the Association of Certified Fraud Examiners (CFE) or an accreditation from the National Health Care Anti-Fraud Association (AHFI).
• Experience performing coding and audit functions within a health plan or payer environment.
• Strong attention to detail and ability to review and interpret data.
• Demonstrates strong written and verbal communication skills.

Education

• AAPC Certified Professional Coder Certification (CPC).
• GED or High School diploma.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$43,888.00 - $93,574.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This fulltime position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments.

We anticipate the application window for this opening will close on: 11/13/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.