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Certified Professional Coder, Special Investigations Unit (Aetna SIU)

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At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.<br><br>As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.<br><br><strong>Position Summary<br><br></strong>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.<br><br><strong>Activities Include<br><br></strong><ul><li> Conduct a comprehensive medical record review to ensure billing is consistent with medical record.</li><li> Provide detailed written summary of medical record review findings.</li><li> Must be able to articulate findings to investigators, Medicaid plan leadership, law enforcement, legal counsel, providers, state regulators, etc.</li><li> Review and discuss cases with Medical Directors to validate decisions.</li><li> Assist with investigative research related to coding questions, state and federal policies.</li><li> Identify potential billing errors, abuse, and fraud.</li><li> Identify opportunities for savings related to potential cases which may warrant a prepayment review.</li><li> Maintain appropriate records, files, documentation, etc.</li><li> Ability to travel for meetings and potential to testify<br><br></li></ul><strong>Required Qualifications<br><br></strong><ul><li> AAPC Coding certification - Certified Professional Coder (CPC).</li><li> 3+ years of experience reviewing and analyzing medical records to determine appropriate CPT and HCPCS code assignments.</li><li> 3+ years’ experience of ensuring coding is accurate and compliant with federal regulations, payer policies, and organizational guidelines.</li><li> Working experience with Microsoft Excel.</li><li> Strong attention to detail and ability to review and interpret data.<br><br></li></ul><strong>Preferred Qualifications<br><br></strong><ul><li> 2 years or more previous experience with medical record review within a healthcare insurance company.</li><li> Prior special investigation unit experience.</li><li> Excellent analytical skills.</li><li> Excellent communication skills.<br><br></li></ul><strong>Education<br><br></strong><ul><li> GED or equivalent</li><li> AAPC Certified Professional Coder Certification (CPC)<br><br></li></ul><strong>Anticipated Weekly Hours<br><br></strong>40<br><br><strong>Time Type<br><br></strong>Full time<br><br><strong>Pay Range<br><br></strong><strong>The Typical Pay Range For This Role Is<br><br></strong>$43,888.00 - $102,081.00<br><br>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.<br><br>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.<br><br><strong>Great Benefits For Great People<br><br></strong>We 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:<br><br><ul><li>Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.</li><li>No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</li><li>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.<br><br></li></ul>For more information, visit anticipate the application window for this opening will close on: 08/29/2025<br><br>Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...

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