Certified Professional Coder (Fully Remote)

Job DescriptionThe 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.Activities include:- 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.Required Qualifications- AAPC Coding certification and 3+ years of experience in medical coding. - Previous experience with Behavioral Health coding/auditing of records- 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 ExcelCOVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred Qualifications- 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 skillsEducation- Certified Professional Coder (AAPC) or other comparable coding certification.Business OverviewBring your heart to CVS HealthEvery 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.Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Created: 2025-11-15