Certified Professional Coder, Special Investigations Unit; Aetna SIU

About Us

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. The CPC must have the ability to determine correct coding and appropriate documentation during the review of medical records. The CPC must also ensure that the 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 detailed written summary of medical record review findings. Must be able to articulate findings to investigators, Medicaid plan leadership, law enforcement, legal counsel, providers, state regulators, etc. 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, documentation, etc. Uses department resources regularly and follows workflows with minimal assistance or intervention to perform daily work to meet metrics.

Maintains up-to-date coding knowledge, including new changes to coding compliance and reimbursement.

• 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.
• The CPC must have the ability to determine correct coding and appropriate documentation during the review of medical records.
• The CPC must also ensure that the 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 detailed written summary of medical record review findings.
• Must be able to articulate findings to investigators, Medicaid plan leadership, law enforcement, legal counsel, providers, state regulators, etc.
• 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, documentation, etc.
• Uses department resources regularly and follows workflows with minimal assistance or intervention to perform daily work to meet metrics.
• Maintains up-to-date coding knowledge, including new changes to coding compliance and reimbursement.

• 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

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

• AAPC Certified Professional Coder Certification (CPC)

Anticipated Weekly Hours 40

Time Type Full time

The typical pay range for this role is:…