Senior Coding Quality Analyst (CPC) – Special Investigations Unit

CVS Health

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary The Senior Coding Quality Analyst (CPC) – Special Investigations Unit 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 comprehensive quality reviews of completed medical coding reviews to ensure coding logic aligns with medical record documentation, CPT/HCPCS/ICD 10 guidelines, and payer, state, and federal requirements. • Perform in depth medical record reviews across medical, behavioral health, transportation, and other healthcare provider claims. • Analyze data, documentation, and evidence to identify potential billing errors, abuse, or fraudulent activity, including concerning billing patterns and trends. • Handle complex coding reviews, including those related to legal, compliance, escalations, audits, and rework initiatives, resolving issues with sensitivity and professionalism. • Prepare detailed written summaries of findings and clearly articulate conclusions to leadership. • Independently research and apply state, CMS, and payer specific guidelines relevant to audits and reviews. • Identify opportunities for process improvements, cost savings, and cases that may warrant prepayment review. • Maintain accurate documentation, records, files, and tracking logs while meeting established deadlines and performance metrics. • Regularly use departmental tools and workflows with minimal assistance to support daily operations. • Provide mentorship and training to coders, offering guidance on coding quality, documentation standards, and review methodology. • Serve as management back up and support team operations in the manager’s absence. • Maintain up to date knowledge of coding standards, compliance changes, reimbursement methodologies, and investigatory best practices. • Encourage innovative approaches to operational challenges and contribute to continuous improvement of investigative methodologies, tools, and processes.

Requirements

AAPC CPC certification
1+ year of reviewing coding consultant decisions for quality purposes
1+ year of developing and implementing quality remediation plans
1+ year of experience in medical coding in a Fraud, Waste, Abuse and/or error department
Strong knowledge of standard industry coding guides and guidelines including CPT, HCPCS, ICD-10,
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 communication skills.

Nice To Haves

Excellent communication skills
Excellent analytical skills
Strong attention to detail and ability to review and interpret data.

Responsibilities

Conduct comprehensive quality reviews of completed medical coding reviews to ensure coding logic aligns with medical record documentation, CPT/HCPCS/ICD 10 guidelines, and payer, state, and federal requirements.
Perform in depth medical record reviews across medical, behavioral health, transportation, and other healthcare provider claims.
Analyze data, documentation, and evidence to identify potential billing errors, abuse, or fraudulent activity, including concerning billing patterns and trends.
Handle complex coding reviews, including those related to legal, compliance, escalations, audits, and rework initiatives, resolving issues with sensitivity and professionalism.
Prepare detailed written summaries of findings and clearly articulate conclusions to leadership.
Independently research and apply state, CMS, and payer specific guidelines relevant to audits and reviews.
Identify opportunities for process improvements, cost savings, and cases that may warrant prepayment review.
Maintain accurate documentation, records, files, and tracking logs while meeting established deadlines and performance metrics.
Regularly use departmental tools and workflows with minimal assistance to support daily operations.
Provide mentorship and training to coders, offering guidance on coding quality, documentation standards, and review methodology.
Serve as management back up and support team operations in the manager’s absence.
Maintain up to date knowledge of coding standards, compliance changes, reimbursement methodologies, and investigatory best practices.
Encourage innovative approaches to operational challenges and contribute to continuous improvement of investigative methodologies, tools, and processes.

Benefits

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
Additional details about available benefits are provided during the application process and on Benefits Moments.

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