Description
Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
The Certified Professional Coder (CPC) will perform medical claim reviews 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.
Roles and Responsibilities
- Conduct a comprehensive medical record review to ensure billing is consistent with medical record.
- 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.
- 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.
- May include travel to testify in court proceedings or training if necessary.
Required Qualifications
- AAPC Coding certification and 3+ years of experience in medical coding.
- 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 Excel.
- Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.
Preferred Qualifications
- Previous experience with Behavioral Health coding/auditing of records.
- Licensed Clinical Social Worker (LCSW).
- Licensed Independent Social Worker (LISW).
- Licensed Master Social Worker (LMSW).
- Strong attention to detail and ability to review and interpret data.
- Prior auditing experience.
- Excellent communication skills.
- Excellent analytical skills.
Education
- Certified Professional Coder (AAPC) or other comparable coding certification.
