SIU Medical & Behavioral Health Coding Analyst

4004 Aetna Medicaid Administrators; Connecticut; Hybrid; USD 44.000 - 94.000; Vollzeit

Benefits dieser Stelle

Medical, dental and vision coverage

Paid time off

Retirement savings options

Wellness programs

Zusammenfassung

CVS Health is seeking a Certified Professional Coder (CPC) to perform medical claim reviews for the Special Investigations Unit (SIU). The candidate will ensure coding accuracy, review medical records, and provide detailed findings to investigators and leadership. Strong knowledge of CPT/HCPCS and Revenue Codes is required, with 3+ years of coding experience.

The role offers full-time employment with a 40-hour work week, benefits, and potential bonuses. Travel may be required.

Qualifikationen

• AAPC CPC certification.
• Minimum 3 years medical/behavioral health coding with 1–2 years of current review experience.
• Knowledge of CPT, HCPCS and Revenue Codes.
• CMS 1500 and UB04 data elements.
• Ability to apply coding policies consistently.
• Experience with Excel and Word.
• Ability to travel if needed.

Aufgaben

• Conduct comprehensive medical record reviews to verify codes match documentation.
• Provide detailed written summaries of findings.
• Articulate findings to investigators and leadership.
• Research CMS/state guidelines related to reviews.
• Review cases with Medical Directors to validate decisions.
• Assist with investigative coding research.
• Identify potential billing errors, abuse, and fraud.
• Identify savings opportunities for prepayment reviews.
• Maintain records and documentation.
• Keep up-to-date coding knowledge.

Kenntnisse

CPC certification

Medical coding experience

CPT/HCPCS knowledge

MS Excel/Word

Travel flexibility

Ausbildung

AAPC CPC Certification

GED or High School diploma

Tools

Microsoft Excel

Microsoft Word

Jobbeschreibung

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.

Benefits

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 full-time 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.

Our Work Experience is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.