Senior Certified Professional Coder, Special Investigations Unit (Aetna SIU)

he 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.
• Maintains up-to-date coding knowledge, including new changes to coding compliance and reimbursement.

Required Qualifications

• AAPC Coding certification - Certified Professional Coder (CPC)
• 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
• Experience with researching coding and policies.
• Experience with Microsoft products; including Excel and Word
• Prior experience auditing others' work and providing feedback.
• Experience mentoring others.
• Must be able to travel to provide testimony if needed.

Preferred Qualifications

• 3+ years or more previous experience with Behavioral Health coding/auditing of records
• 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
• Strong attention to detail and ability to review and interpret data.

Education

• AAPC Certified Professional Coder Certification (CPC)
• GED or High School diploma

Anticipated Weekly Hours
40Time Type
Full timePay Range

The typical pay range for this role is:$46,988.00 - $112,200.00This 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.Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.Great benefits for great peopleWe take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefitsWe anticipate the application window for this opening will close on: 12/06/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.