Analyst, Special Investigative Unit, CVS Health

CVS Health

Location:
United States, Work At Home

Category:
Customer Service

Contract Type:
Not provided

Salary:

43888.00 - 85068.00 USD / Year

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Job Description:

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.

Job Responsibility:

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

Requirements:

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

Nice to have:

2 years or more previous experience with medical record review within a healthcare insurance company
Prior special investigation unit experience
Excellent analytical skills
Excellent communication skills

What we offer:

Affordable medical plan options
401(k) plan (including matching company contributions)
Employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility

Additional Information:

Job Posted:
August 14, 2025

Expiration:
September 15, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Analyst, Special Investigative Unit