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CVS Health
CVS Health
HealthcareHealthcare InsuranceRetail
CVS Health is an American healthcare company working across healthcare services, health insurance, pharmacy benefits management, and retail pharmacy. Through businesses including Aetna and CVS Caremark, it supports health coverage, prescription access, condition management, specialty medications, and mail-order pharmacy services. Its neighborhood pharmacies and broader care offerings are designed to help people access essential healthcare more conveniently and affordably. CVS Health brings together insurance, pharmacy, and health services to support individuals and communities throughout their care journeys.
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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.

USUnited StatesMNMinnesota
$46,988 – $102,000 / year
HybridFull-timeSeniorEnglish RequiredAnalyst

Description

  • 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.

Requirements

  • 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.

Benefits

  • 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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