SIU Medical Coding & Fraud Audit Analyst

Voices for Voices; City of Albany (NY); Hybrid; USD 44,000 - 94,000; Full time

Benefits offered by this job

Competitive benefits

Medical, dental, and vision coverage

Paid time off

Job summary

CVS Health is seeking a Certified Professional Coder (CPC) for the Special Investigations Unit to perform medical claim reviews and ensure coding accuracy and compliant documentation. The role requires CPC certification, 3+ years of medical/behavioral health coding with 1-2 years of current coding experience, and proficiency with CPT/HCPCS, CMS 1500 and UB04 forms.

Travel may be required. You'll articulate findings to investigators and leaders, identify potential fraud or billing errors, and

Qualifications

• Must hold AAPC CPC certification.
• 3+ years of medical/behavioral health coding experience including medical record review and documentation auditing.
• Knowledge of CPT, CPT- HCPCS, and Revenue Codes.
• CMS 1500 and UB04 data elements.
• Ability to interpret and apply established coding policies and guidelines.
• Experience with Microsoft Excel and Word.
• Willingness to travel for the role.

Responsibilities

• Conduct comprehensive medical record reviews to ensure CPT/HCPCS/revenue codes align with documentation.
• Provide detailed written summaries of review findings.
• Articulate findings to investigators, plan leadership, law enforcement, legal counsel, providers, regulators.
• Research and apply state or CMS guidelines related to reviews.
• Discuss cases with Medical Directors to validate decisions.
• Assist with investigative research related to coding questions/policies.
• Identify potential billing errors, abuse and fraud.
• Identify opportunities for savings needing prepayment review.
• Maintain records and follow workflows to meet metrics.
• Maintain up-to-date coding knowledge with changes in policy and reimbursement.

Skills

CPC certification

Medical coding

Medical record review

Documentation auditing

CPT/HCPCS knowledge

CMS 1500/UB04

Excel

Travel

Education

AAPC CPC Certification

GED or High School diploma

Tools

MS Office (Excel/Word)

Job description

CVS Health is seeking a Certified Professional Coder (CPC) for the Special Investigations Unit to perform medical claim reviews and ensure coding accuracy and compliant documentation. The role requires CPC certification, 3+ years of medical/behavioral health coding with 1-2 years of current coding experience, and proficiency with CPT/HCPCS, CMS 1500 and UB04 forms.

Travel may be required. You'll articulate findings to investigators and leaders, identify potential fraud or billing errors, and