Senior Certified Professional Coder, CVS Health

CVS Health

Location:
United States

Category:
-

Contract Type:
Not provided

Salary:

46988.00 - 112200.00 USD / Year

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Job Description:

Senior Certified Professional Coder will perform medical claim reviews for the Special Investigations Unit (SIU) to ensure compliance with coding practices through comprehensive record review for medical, behavioral, transportation and other healthcare providers. The role involves determining correct coding and appropriate documentation during medical record reviews while ensuring state, federal and company requirements are met.

Job Responsibility:

Perform medical claim reviews for the Special Investigations Unit (SIU) to ensure compliance with coding practices
Conduct comprehensive medical record audit to ensure CPT/HCPCS or modifiers billed are consistent with medical record documentation
Handle complex coding reviews and resolve complex issues with sensitivity
Provide detailed written summary of medical record review findings
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
Independently research and accurately apply state or CMS guidelines related to the audit
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
Mentor New Coders, providing training, coding, and record review guidance
Collaboration with investigators, data analytics and plan leadership on SIU schemes
Act as management back-up and support the team when the manager is out of the office
Maintain up-to-date coding knowledge, including new changes to coding compliance and reimbursement

Requirements:

AAPC Coding certification - Certified Professional Coder (CPC)
3+ years of experience in medical coding or documentation auditing
Strong 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 including Excel and Word
Prior experience auditing others' work and providing feedback
Experience mentoring others
Must be able to travel to provide testimony if needed

Nice to have:

3+ years or more previous experience with Behavioral Health coding/auditing of records
Licensed Clinical Social Worker (LCSW)
Licensed Independent Social Worker (LISW)
Licensed Master Social Worker (LMSW)
Licensed Professional Counselor (LPC)
Excellent communication skills
Excellent analytical skills
Strong attention to detail and ability to review and interpret data

What we offer:

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
No-cost wellness screenings
Tobacco cessation programs
Weight management programs
Confidential counseling
Financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources
Colleague assistance programs
Tuition assistance
Retiree medical access

Additional Information:

Job Posted:
November 24, 2025

Expiration:
December 06, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Senior Certified Professional Coder