Special Investigation Unit (SIU) Coding Review Manager, CVS Health

CVS Health

Location:
United States

Category:
Customer Service

Contract Type:
Not provided

Salary:

54300.00 - 159120.00 USD / Year

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Job Description:

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s 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. The Certified Professional Coder (CPC) Manager will oversee a team of medical coders within the Special Investigations Unit (SIU) to ensure compliance with coding practices through comprehensive record reviews for medical, behavioral, transportation, and other healthcare providers. The CPC Manager will be responsible for guiding the team in determining correct coding and appropriate documentation during the review of medical records. This role requires a strong focus on meeting state, federal, and company requirements while identifying concerning billing patterns or trends.

Job Responsibility:

Lead and mentor a team of CPCs, providing training, guidance, and support in coding practices and medical record reviews
Conduct regular audits of team performance to ensure compliance with CPT/HCPCS coding and documentation standards
Establish team goals, monitor performance, and ensure alignment with organizational objectives
Direct and oversee complex coding reviews and resolve intricate issues with sensitivity, including claim reviews for legal, compliance, or rework projects
Ensure staff provide detailed written summaries of medical record review findings and ensure the team articulates findings effectively to investigators, Medicaid plan leadership, law enforcement, legal counsel, providers, and state regulators
Conducts team member evaluations and provides performance feedback to staff on an ongoing basis
Collaborate with Medical Directors to validate decisions and discuss complex cases
Manages workload of their team to ensure equitable distribution and exposure to wide range of cases to match current skills and development needs
Assist with investigative research related to coding questions, state and federal policies, and identify potential billing errors, abuse, and fraud
Identify opportunities for savings related to potential cases that may warrant a prepayment review
Maintain appropriate records, files, and documentation for the team
Utilize department resources effectively and ensure workflows are followed to meet performance metrics
Collaborate with investigators, data analytics, and plan leadership on SIU schemes and initiatives
Act as the primary point of contact for the team in the absence of the director, ensuring continuity of operations and support
Develop and implement training and onboarding programs for new team members

Requirements:

A minimum of 2 years of managing a staff
Coding Certification (CPC, CPMA, COC)
A minimum of 5 years of experience in medical record review for coding accuracy
Strong knowledge of standard industry coding guides and guidelines, including CPT, HCPCS, ICD-10, CMS 1500, and UB04 data elements
Maintains up-to-date coding knowledge, including new changes to coding compliance and reimbursement
Experience with researching coding and policies
Proficiency in Microsoft products, particularly Excel and Word
Strong attention to detail and ability to review and interpret data
Demonstrates strong communication and leadership skills

Nice to have:

A minimum of 2 years of managing staff within a Special Investigation Unit (SIU)
Excellent analytical skills and the ability to mentor and develop team members
Registered Nurse (RN)
Previous experience with Behavioral Health coding/auditing of records

What we offer:

Affordable medical plan options, a 401(k) plan (including matching company contributions), and an 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 05, 2025

Expiration:
September 06, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Special Investigation Unit (SIU) Coding Review Manager