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

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.

Required Qualifications

• 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.

Preferred Qualifications
• 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

Time Type

Pay Range

The typical pay range for this role is:

This 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 people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Additional details about available benefits are provided during the application process and on Benefits Moments.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.