Certified Coding Auditor (CPC), Analyst

CVS Health•Hartford, CT

2d•Remote

About The Position

The Certified Coding Analyst will perform medical claim reviews for waste and error to ensure compliance with coding practices through a comprehensive record review for medical and institutional providers. The Analyst must have the ability to determine correct coding and appropriate documentation during the review of medical records. The Analyst must also ensure state; federal and company requirements are met. Conduct a comprehensive medical record audit to ensure the CPT/HCPCS or modifiers billed are consistent with medical record documentation. Research and accurately apply state, CMS and organizational guidelines related to the audit with minimal support. Review and discuss cases with Medical Directors to validate decisions as needed. Assist with investigative research related to coding questions, state and federal policies. Identify potential billing errors, abuse, and fraud. Prepare clear, concise summary of findings Ability to present case outcomes and decision rationale in a clear, concise manner to internal partners. Track and trend recurring coding and billing issues to inform process improvements and provider education. Maintain appropriate records, files, documentation, etc. Uses department resources regularly Follows workflows with minimal assistance to perform daily work to meet production metrics

Requirements

AAPC Certified professional Coder (CPC) certification
2+ years of experience in medical coding, claims review, auditing
Strong knowledge of standard industry coding guides and guidelines including CPT, HCPCS, ICD-10, and modifiers
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.
Demonstrates strong written and verbal communication skills

Nice To Haves

1+ years of experience in appeal/recon medical coding, claims reviews, auditing
Medicaid auditing experience
Prior auditing experience in fraud, waste, abuse and error, or payment integrity
Excellent communication skills
Strong analytical and problem-solving skills
Encoder pro experience

Responsibilities

Perform medical claim reviews for waste and error to ensure compliance with coding practices through a comprehensive record review for medical and institutional providers.
Determine correct coding and appropriate documentation during the review of medical records.
Ensure state, federal and company requirements are met.
Conduct a comprehensive medical record audit to ensure the CPT/HCPCS or modifiers billed are consistent with medical record documentation.
Research and accurately apply state, CMS and organizational guidelines related to the audit with minimal support.
Review and discuss cases with Medical Directors to validate decisions as needed.
Assist with investigative research related to coding questions, state and federal policies.
Identify potential billing errors, abuse, and fraud.
Prepare clear, concise summary of findings.
Present case outcomes and decision rationale in a clear, concise manner to internal partners.
Track and trend recurring coding and billing issues to inform process improvements and provider education.
Maintain appropriate records, files, documentation, etc.
Use department resources regularly.
Follow workflows with minimal assistance to perform daily work to meet production metrics.