SIU Medical Coding & Compliance Analyst

CVS Health Corporation; Springfield (IL); On-site; USD 44,000 - 94,000; Full time

Job summary

CVS Health Corporation is seeking a Certified Professional Coder (CPC) in Illinois to perform medical claim reviews for the Special Investigations Unit (SIU). The role involves verifying CPT/HCPCS/Revenue codes against records, producing detailed findings, and communicating results to investigators and regulators.

Travel may be required, with opportunities to support fraud detection and reimbursement compliance.

Qualifications

• Requires 3+ years of medical or behavioral health coding experience with record review and auditing.
• Must interpret and apply CPT, HCPCS, and Revenue Codes consistently.
• CMS 1500 and UB04 data elements knowledge.

Responsibilities

• Perform comprehensive medical record reviews to verify CPT/HCPCS/Revenue Codes align with documentation.
• Provide detailed written summaries of review findings for investigators and leadership.
• Articulate findings to investigators, plan leadership, law enforcement, legal counsel, providers and regulators as needed.
• Research CMS/state guidelines and apply them to coding reviews with minimal support.
• Discuss cases with Medical Directors to validate decisions and ensure accuracy.
• Assist with coding-related investigations and identify potential fraud or errors.
• Identify opportunities for cost savings related to potential prepayment reviews.
• Maintain organized records and follow established workflows to meet metrics.
• Keep up-to-date knowledge of coding changes and reimbursement practices.

Skills

CPC certification

Medical coding experience

Attention to detail

Communication skills

Education

AAPC CPC certification

GED or High School diploma

Tools

Microsoft Excel

Word

Job description

CVS Health Corporation is seeking a Certified Professional Coder (CPC) in Illinois to perform medical claim reviews for the Special Investigations Unit (SIU). The role involves verifying CPT/HCPCS/Revenue codes against records, producing detailed findings, and communicating results to investigators and regulators.

Travel may be required, with opportunities to support fraud detection and reimbursement compliance.