Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. The Senior Certified Professional Coder (CPC) 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. **Activities include:** + Conduct a comprehensive medical record audit to ensure the CPT/HCPCS or modifiers billed are consistent with medical record documentation. + Handles complex coding reviews and will resolve complex issues with sensitivity. Including but not limited to claim reviews for legal, compliance or rework projects. + 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. + 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, etc. + Uses department resources regularly and follows workflows with no assistance or intervention to perform daily work to meet metrics. + 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 supports the team when the manager is out of the office. **Required Qualifications:** + AAPC Coding certification + 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 + 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. + Three + years or more previous experience with Behavioral Health coding/auditing of records + Demonstrates strong communication skills. + Prior auditing experience **Preferred Qualifications:** - 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 **Education-** -AAPC Certified Professional Coder Certification (CPC) -GED or High School diploma **Pay Range** The typical pay range for this role is: $46,988.00 - $112,200.00 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies. For more detailed information on available benefits, please visit Benefits | CVS Health (https://jobs.cvshealth.com/us/en/benefits) We anticipate the application window for this opening will close on: 01/02/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.