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Senior Coding Quality Analyst (CPC) – Special Investigations Unit
CVS Health
Location:
United States , Work at Home
Category:
-
Contract Type:
Employment contract
Salary:
46988.00 - 102000.00 USD / Year
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Job offer has expired
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. Position Summary: The Senior Coding Quality Analyst (CPC) – Special Investigations Unit 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.
Job Responsibility:
Conduct comprehensive quality reviews of completed medical coding reviews to ensure coding logic aligns with medical record documentation, CPT/HCPCS/ICD 10 guidelines, and payer, state, and federal requirements
Perform in depth medical record reviews across medical, behavioral health, transportation, and other healthcare provider claims
Analyze data, documentation, and evidence to identify potential billing errors, abuse, or fraudulent activity, including concerning billing patterns and trends
Handle complex coding reviews, including those related to legal, compliance, escalations, audits, and rework initiatives, resolving issues with sensitivity and professionalism
Prepare detailed written summaries of findings and clearly articulate conclusions to leadership
Independently research and apply state, CMS, and payer specific guidelines relevant to audits and reviews
Identify opportunities for process improvements, cost savings, and cases that may warrant prepayment review
Maintain accurate documentation, records, files, and tracking logs while meeting established deadlines and performance metrics
Regularly use departmental tools and workflows with minimal assistance to support daily operations
Provide mentorship and training to coders, offering guidance on coding quality, documentation standards, and review methodology
Serve as management back up and support team operations in the manager’s absence
Maintain up to date knowledge of coding standards, compliance changes, reimbursement methodologies, and investigatory best practices
Encourage innovative approaches to operational challenges and contribute to continuous improvement of investigative methodologies, tools, and processes
Requirements:
AAPC CPC certification
1+ year of reviewing coding consultant decisions for quality purposes
1+ year of developing and implementing quality remediation plans
1+ year of experience in medical coding in a Fraud, Waste, Abuse and/or error department
Strong knowledge of standard industry coding guides and guidelines including CPT, HCPCS, ICD-10
Maintains up-to-date coding knowledge, including new changes to coding compliance and reimbursement
Experience with researching coding and policies
Experience with Microsoft products
Excel and Word
Strong attention to detail and ability to review and interpret data
Demonstrates strong communication skills
GED or High School diploma
Nice to have:
Excellent communication skills
Excellent analytical skills
Strong attention to detail and ability to review and interpret data