Job Details

Certified Professional Coder, Special Investigations Unit (Aetna SIU) at CVS Health in Boise, Idaho, United States Job Description At CVS Health, were building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nations leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position Summary The Certified Professional Coder (CPC) will perform medical claim reviews 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. Activities include: - Conduct a comprehensive medical record review to ensure billing is consistent with medical record. - 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. - 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. - Ability to travel for meetings and potential to testify Required Qualifications - AAPC Coding certification - Certified Professional Coder (CPC). - 3+ years of experience reviewing and analyzing medical records to determine appropriate CPT and HCPCS code assignments. - 3+ years experience of ensuring coding is accurate and compliant with federal regulations, payer policies, and organizational guidelines. - Working experience with Microsoft Excel. - Strong attention to detail and ability to review and interpret data. Preferred Qualifications - 2 years or more previous experience with medical record review within a healthcare insurance company. - Prior special investigation unit experience. - To view full details and how to apply, please login or create a Job Seeker account