Special Investigation Unit (SIU) Manager

CVS Health

2d•$54,300 - $159,120•Onsite

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. The Certified Professional Coder (CPC) Manager will oversee a team of medical coders within the Special Investigations Unit (SIU) to ensure compliance with coding practices through comprehensive record reviews for medical, behavioral, transportation, and other healthcare providers. Role Overview: The CPC Manager will be responsible for guiding the team in determining correct coding and appropriate documentation during the review of medical records. This role requires a strong focus on meeting state, federal, and company requirements while identifying concerning billing patterns or trends.

Requirements

AAPC Coding certification.
5+ 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.
3 + years in a leadership role required
Proficiency in Microsoft products, particularly Excel and Word.
Strong attention to detail and ability to review and interpret data.
Demonstrates strong communication and leadership skills.
Excellent analytical skills and the ability to mentor and develop team members.

Nice To Haves

Prior auditing experience is preferred.

Responsibilities

Lead and mentor a team of CPCs, providing training, guidance, and support in coding practices and medical record reviews.
Conduct regular audits of team performance to ensure compliance with CPT/HCPCS coding and documentation standards.
Establish team goals, monitor performance, and ensure alignment with organizational objectives.
Direct and oversee complex coding reviews and resolve intricate issues with sensitivity, including claim reviews for legal, compliance, or rework projects.
Ensure staff provide detailed written summaries of medical record review findings and ensure the team articulates findings effectively to investigators, Medicaid plan leadership, law enforcement, legal counsel, providers, and state regulators.
Conducts team member evaluations and provides performance feedback to staff on an ongoing basis.
Collaborate with Medical Directors to validate decisions and discuss complex cases.
Manages workload of their team to ensure equitable distribution and exposure to wide range of cases to match current skills and development needs.
Assist with investigative research related to coding questions, state and federal policies, and identify potential billing errors, abuse, and fraud.
Identify opportunities for savings related to potential cases that may warrant a prepayment review.
Maintain appropriate records, files, and documentation for the team.
Utilize department resources effectively and ensure workflows are followed to meet performance metrics.
Collaborate with investigators, data analytics, and plan leadership on SIU schemes and initiatives.
Act as the primary point of contact for the team in the absence of the director, ensuring continuity of operations and support.
Develop and implement training and onboarding programs for new team members