Certified Professional Coder, Special Investigations Unit (Aetna SIU)

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. This is a work-from-home position based in Texas.

What You'll Do

You will have the ability to determine correct coding and appropriate documentation during the review of medical records. You must also ensure that state, federal and company requirements are met and recognize any concerning billing patterns or trends.

Conduct a comprehensive medical record audit to ensure the CPT/HCPCS or modifiers billed are consistent with medical record documentation. Provide a detailed written summary of medical record review findings. You must be able to articulate findings to investigators, Medicaid plan leadership, law enforcement, legal counsel, providers, state regulators, and others.

Research and accurately apply state or CMS guidelines related to the audit 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, and documentation. Use department resources regularly and follow workflows with minimal assistance or intervention to perform daily work and meet metrics. Maintain up-to-date coding knowledge, including new changes to coding compliance and reimbursement.

Required Qualifications

• AAPC Certified Professional Coder Certification (CPC)
• 3+ years of experience in medical coding or documentation auditing
• Knowledge of standard industry coding guides and guidelines including CPT, HCPCS, ICD-10, CMS 1500 and UB04 data elements
• Experience with researching coding and policies
• Experience with Microsoft products, specifically Excel and Word

Preferred Qualifications

• CPMA certification is highly desirable
• Strong attention to detail and ability to review and interpret data
• Demonstrates strong communication skills
• Prior payor auditing experience
• Excellent communication and analytical skills
• Two years or more previous experience with Behavioral Health coding/auditing of records

Education

• GED or equivalent
• AAPC Certified Professional Coder Certification (CPC)

Compensation and Benefits

• Pay Range: $43,888.00 - $93,574.00 per year
• This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above
• Comprehensive benefits package including medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility
• 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.
• This is a full-time position with anticipated weekly hours of
• 40. We anticipate the application window for this opening will close on: 08/22/20
• 26. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.