SIU Investigator

Summary

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.Maintains up-to-date coding knowledge, including new changes to coding compliance and reimbursement.Required QualificationsAAPC CPC certificationMinimum 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.Preferred QualificationsCPMA certificationCredentials such as certification from the Association of Certified Fraud Examiners (CFE) or an accreditation from the National Health Care Anti-Fraud Association (AHFI).Experience performing coding and audit functions within a health plan or payer environment.Strong attention to detail and ability to review and interpret data.Demonstrates strong written and verbal communication skills.EducationAAPC Certified Professional Coder Certification (CPC).GED or High School diploma.Anticipated Weekly Hours40Time TypeFull timePay RangeThe typical pay range for this role is: $43,888.00 - $93,574.00This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.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.Great benefits for great peopleWe take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.Additional details about available benefits are provided during the application process and on Benefits Moments.We anticipate the application window for this opening will close on: 11/13/2026Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.#J-18808-Ljbffr

Job Description

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.Maintains up-to-date coding knowledge, including new changes to coding compliance and reimbursement.Required QualificationsAAPC CPC certificationMinimum 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.Preferred QualificationsCPMA certificationCredentials such as certification from the Association of Certified Fraud Examiners (CFE) or an accreditation from the National Health Care Anti-Fraud Association (AHFI).Experience performing coding and audit functions within a health plan or payer environment.Strong attention to detail and ability to review and interpret data.Demonstrates strong written and verbal communication skills.EducationAAPC Certified Professional Coder Certification (CPC).GED or High School diploma.Anticipated Weekly Hours40Time TypeFull timePay RangeThe typical pay range for this role is: $43,888.00 - $93,574.00This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.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.Great benefits for great peopleWe take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.Additional details about available benefits are provided during the application process and on Benefits Moments.We anticipate the application window for this opening will close on: 11/13/2026Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.#J-18808-Ljbffr