CVS Health · 6 days ago

Senior Certified Professional Coder (Aetna SIU)

Connecticut, United States

Full-time

Remote

Mid, Senior Level

$47K/yr - $112K/yr

3+ years exp

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Responsibilities

Conduct a comprehensive medical record audit to ensure the CPT/HCPCS or modifiers billed are consistent with medical record documentation.

Handles complex coding reviews and will resolve complex issues with sensitivity. Including but not limited to claim reviews for legal, compliance or rework projects.

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.

Independently research and accurately apply state or CMS guidelines related to the audit.

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.

Uses department resources regularly and follows workflows with no assistance or intervention to perform daily work to meet metrics.

Mentor New Coders, providing training, coding, and record review guidance.

Collaboration with investigators, data analytics and plan leadership on SIU schemes.

Act as management back-up and supports the team when the manager is out of the office.

Qualification

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AAPC Coding certificationMedical coding experienceCPT codingICD-10 codingHCPCS codingCMS 1500UB04 data elementsMicrosoft ExcelMicrosoft WordBehavioral Health codingAuditing experienceLicensed Clinical Social Worker (LCSW)Licensed Independent Social Worker (LISW)Licensed Master Social Worker (LMSW)Licensed Professional Counselor (LPC)