Certified Professional Coder, Special Investigations Unit (Aetna SIU)

CVS Health

4d•$43,888 - $93,574

About The Position

The 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.

Requirements

AAPC Certified Professional Coder Certification (CPC)
3+ years of experience in medical coding or documentation auditing.
Knowledge of standard industry coding guides and guidelines including CPT, HCPCS, ICD-10, CMS 1500 and UB04 data elements
Experience with researching coding and policies.
Experience with Microsoft products, specifically Excel and Word

Nice To Haves

CPMA
Strong attention to detail and ability to review and interpret data.
Demonstrates strong communication skills.
Prior payor auditing experience
Excellent communication skills
Excellent analytical skills
Two years or more previous experience with Behavioral Health coding/auditing of records

Responsibilities

Conduct a comprehensive medical record audit to ensure the CPT/HCPCS or modifiers billed are consistent with medical record documentation.
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.
Research and accurately apply state or CMS guidelines related to the audit with minimal support.
Review and discuss cases with Medical Directors to validate decisions.
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 minimal assistance or intervention to perform daily work to meet metrics.
Maintains up-to-date coding knowledge, including new changes to coding compliance and reimbursement.