Certified Coding Auditor (CPC), Analyst

Summary

CVS Health is building a more connected, convenient, and compassionate health care experience. The Certified Coding Auditor (CPC), Analyst performs comprehensive medical claim and record reviews to ensure coding compliance, identify billing errors, abuse, and fraud, and apply relevant state, CMS, and organizational guidelines. The role also prepares findings, collaborates with Medical Directors and internal partners, and tracks recurring issues for process improvement and provider education.

Responsibilities

• Conduct a comprehensive medical record audit to ensure the CPT/HCPCS or modifiers billed are consistent with medical record documentation
• Research and accurately apply state, CMS and organizational guidelines related to the audit with minimal support
• Review and discuss cases with Medical Directors to validate decisions as needed
• Assist with investigative research related to coding questions, state and federal policies
• Identify potential billing errors, abuse, and fraud
• Prepare clear, concise summary of findings
• Ability to present case outcomes and decision rationale in a clear, concise manner to internal partners
• Track and trend recurring coding and billing issues to inform process improvements and provider education
• Maintain appropriate records, files, documentation, etc
• Uses department resources regularly
• Follows workflows with minimal assistance to perform daily work to meet production metrics

Skills

• AAPC Certified professional Coder (CPC) certification
• 2+ years of experience in medical coding, claims review, auditing
• Strong knowledge of standard industry coding guides and guidelines including CPT, HCPCS, ICD-10, and modifiers
• CMS 1500 and UB04 data elements
• Maintains up-to-date coding knowledge, including new changes to coding compliance and reimbursement
• Experience with researching coding and policies
• Experience with Microsoft products; Excel and Word
• Strong attention to detail and ability to review and interpret data
• Demonstrates strong written and verbal communication skills
• AAPC Certified Professional Coder Certification (CPC)
• High School diploma or GED
• 1+ years of experience in appeal/recon medical coding, claims reviews, auditing
• Medicaid auditing experience
• Prior auditing experience in fraud, waste, abuse and error, or payment integrity
• Excellent communication skills
• Strong analytical and problem-solving skills
• Encoder pro experience

Qualifications

Must Haves

• AAPC Certified professional Coder (CPC) certification
• 2+ years of experience in medical coding, claims review, auditing
• Strong knowledge of standard industry coding guides and guidelines including CPT, HCPCS, ICD-10, and modifiers
• CMS 1500 and UB04 data elements
• Maintains up-to-date coding knowledge, including new changes to coding compliance and reimbursement
• Experience with researching coding and policies
• Experience with Microsoft products; Excel and Word
• Strong attention to detail and ability to review and interpret data
• Demonstrates strong written and verbal communication skills
• AAPC Certified Professional Coder Certification (CPC)
• High School diploma or GED

Nice to Haves

• 1+ years of experience in appeal/recon medical coding, claims reviews, auditing
• Medicaid auditing experience
• Prior auditing experience in fraud, waste, abuse and error, or payment integrity
• Excellent communication skills
• Strong analytical and problem-solving skills
• Encoder pro experience

Benefits

• Eligibility for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
• Medical coverage
• Dental coverage
• Vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Work at home / remote-hybrid work arrangement