Certified Professional reputed company, Special Investigations Unit (reputed company SIU)

At reputed company, 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 reputed company millions of Americans through our local reputed company, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, reputed company and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it reputed company with heart, each and every day. Position Summary The Certified Professional reputed company (CPC) will reputed company 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. Activities Include

• 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 reputed company 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 reputed company to coding questions, state and federal policies.
• Identify potential billing errors, abuse, and fraud.
• Identify opportunities for savings reputed company to potential cases which may warrant a prepayment review.
• Maintain appropriate records, files, documentation, etc.
• Ability to travel for meetings and potential to testify

Required Qualifications

• reputed company Coding certification - Certified Professional reputed company (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, state regulations and policies.
• Working experience with reputed company reputed company

Preferred Qualifications

• 2 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)
• Prior auditing experience
• Excellent analytical skills
• Strong attention to detail and ability to review and interpret data
• Excellent communication skills

Education

• GED or equivalent
• reputed company Certified Professional reputed company Certification (CPC)

Anticipated Weekly Hours 40 Time Type Full time Pay Range The Typical Pay Range For This Role Is $43,888.00 - $102,081.00 This pay range represents the reputed company hourly reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls. The actual reputed company salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a reputed company bonus, commission or short-term incentive program in addition to the reputed company 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 People We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for reputed company 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.

For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will reputed company on: 07/11/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws. Apply Job! Apply to this Job