SIU Medical Coding & Fraud Audit Analyst

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

Job summary

CVS Health Corporation seeks a Certified Professional Coder (CPC) to perform detailed medical record reviews for the Special Investigations Unit, ensuring CPT/HCPCS/revenue code accuracy and compliant documentation. The role involves communicating findings to investigators and leadership, applying CMS guidelines, and identifying potential fraud or savings opportunities.

The role requires CPC certification, 3+ years coding experience (including record review), proficiency in CPT/HCPCS codes, and

Qualifications

• AAPC CPC certification required.
• 3+ years in medical/behavioral health coding with 1-2 years of current professional coding experience including medical record review and documentation auditing.
• Knowledge of CPT, HCPCS, and Revenue Codes; CMS 1500 and UB04 data elements.
• Ability to interpret and apply established coding policies and guidelines.
• Proficiency with Microsoft Excel and Word.
• Ability to travel for the role.

Responsibilities

• Conduct comprehensive medical record reviews to ensure codes and modifiers align with documentation.
• Provide detailed written summaries of review findings.
• Articulate findings to investigators, leadership, regulators and other stakeholders.
• Research and apply state or CMS guidelines related to reviews with minimal support.
• Discuss cases with Medical Directors to validate decisions.
• Assist with investigative research related to coding questions and policies.
• Identify potential billing errors, abuse, fraud and savings opportunities.
• Maintain organized records and comply with workflows to meet metrics.
• Maintain up-to-date coding knowledge with changes to compliance and reimbursement.

Skills

Medical coding

Documentation auditing

Analytical thinking

Written communication

Verbal communication

Travel willingness

Education

AAPC CPC certification

GED or High School diploma

Tools

Excel

Word

Job description

CVS Health Corporation seeks a Certified Professional Coder (CPC) to perform detailed medical record reviews for the Special Investigations Unit, ensuring CPT/HCPCS/revenue code accuracy and compliant documentation. The role involves communicating findings to investigators and leadership, applying CMS guidelines, and identifying potential fraud or savings opportunities.

The role requires CPC certification, 3+ years coding experience (including record review), proficiency in CPT/HCPCS codes, and