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Senior Coding Quality Analyst, Special Investigations
Review coding quality for CVS Health’s Special Investigations Unit, assessing healthcare claims for accuracy and compliance. Identify potential billing errors, fraud, waste, abuse, and suspicious patterns.
संयुक्त राज्य
मिनेसोटा$46,988 – $1,02,000 / वर्ष
हाइब्रिडपूर्णकालिकवरिष्ठआवश्यक भाषा: अंग्रेज़ीविश्लेषकविवरण
- Review completed medical coding assessments for consistency with clinical records, CPT, HCPCS, and ICD-10 guidance, and payer, state, and federal rules.
- Examine medical records tied to claims from medical, behavioral health, transportation, and other healthcare providers.
- Assess data, records, and evidence for possible billing errors, abuse, fraud, and unusual billing patterns or trends.
- Manage complex coding reviews related to legal and compliance matters, escalations, audits, and rework.
- Document findings in detailed written reports and explain conclusions to leadership.
- Research and apply state, CMS, and payer-specific rules to audits and reviews.
- Spot opportunities to improve processes, reduce costs, and flag cases for prepayment review.
- Keep documentation, records, files, and tracking logs accurate while meeting deadlines and performance targets.
- Use departmental systems and workflows to support day-to-day operations.
- Coach and train coders in quality, documentation standards, and review methods.
- Step in for management and support team operations when the manager is absent.
- Stay current on coding standards, compliance updates, reimbursement methods, and investigative practices.
- Help improve investigative methods, tools, and processes.
आवश्यकताएँ
- AAPC CPC certification.
- At least one year reviewing coding consultant decisions for quality.
- At least one year developing and implementing quality remediation plans.
- At least one year of medical coding experience in a fraud, waste, abuse, or error department.
- Knowledge of standard coding references and guidelines, including CPT, HCPCS, and ICD-10.
- Experience researching coding rules and policies.
- Experience with Microsoft products, including Excel and Word.
- GED or high school diploma.
- CPMA certification preferred.
- Excellent communication skills preferred.
- Excellent analytical skills preferred.
- Strong attention to detail and ability to review and interpret data preferred.
लाभ
- Medical coverage.
- Dental coverage.
- Vision coverage.
- Paid time off.
- Retirement savings options.
- Wellness programs.
- Resources supporting physical, emotional, and financial well-being.
- Eligibility for CVS Health bonus, commission, or short-term incentive programs.
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