[Hiring] Medical & Behavioral Health Coding Analyst @CVS Health

Role Description

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 review to ensure the CPT/HCPCS/Revenue codes and/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, plan leadership, law enforcement, legal counsel, providers, state regulators, etc.
• Research and accurately apply state or CMS guidelines related to the review 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.

Qualifications

• AAPC CPC certification
• Minimum of 3 years of experience in medical and/or behavioral health professional coding, with at least 1-2 years of current professional coding experience, including medical record review and documentation auditing.
• Knowledge of professional medical coding systems, including CPT, HCPCS, and Revenue Codes.
• CMS 1500 and UB04 data elements.
• Demonstrated ability to interpret, apply, and consistently apply established coding policies and guidelines.
• Experience with Microsoft products; Excel and Word.
• Ability to travel for the role, if needed.

Requirements

• CPMA certification (preferred)
• Credentials such as certification from the Association of Certified Fraud Examiners (CFE) or an accreditation from the National Health Care Anti-Fraud Association (AHFI) (preferred)
• Experience performing coding and audit functions within a health plan or payer environment (preferred)
• Strong attention to detail and ability to review and interpret data (preferred)
• Demonstrates strong written and verbal communication skills (preferred)

Education

• AAPC Certified Professional Coder Certification (CPC)
• GED or High School diploma

Benefits

• Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.
• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources, based on eligibility.