Certified Professional Coder, Special Investigations Unit (Aetna SIU)
Core
Perform medical claim reviews to ensure compliance with coding practices and identify billing errors, abuse, and fraud across medical, behavioral, and transportation healthcare providers.
Role type
Senior IC medical coding auditor (special investigations)
Builds
Compliance audits and fraud detection reports for CVS Health's Special Investigations Unit
Domain
Healthcare administration / Medical billing compliance
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Medical coding (CPT, HCPCS, Revenue Codes, CMS 1500, UB04), Medical record auditing, Regulatory research (state/federal), Data analysis (Excel), Written reporting, Articulation of findings to investigators/legal counsel
Preferred skills
Behavioral health coding/auditing, Prior auditing experience, Analytical skills
Technologies
Microsoft Excel, CMS 1500, UB04
Responsibilities
Conduct comprehensive medical record reviews to verify billing consistency; Identify potential billing errors, abuse, and fraud; Provide detailed written summaries of review findings; Discuss cases with Medical Directors to validate decisions; Assist with investigative research on coding questions and policies; Maintain records and documentation; Articulate findings to investigators, regulators, and legal counsel.
Seniority
Mid-level, hands-on IC
