Special Investigation Unit Manager Clinical Certified Professional Coder (Aetna SIU)

Bring your heart to CVS Health. Every 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.

The Special Investigations Unit is seeking a Manager to lead our team of Certified Professional Coders (CPC).

 

The Manager is responsible for overseeing and managing coding reviews for fraud detection, investigation, and prevention efforts to safeguard the organization’s resources and reduce healthcare costs. This role involves leading a team of CPC’s, working closely with internal and external stakeholders and ensuring compliance with regulatory requirements. The Manager develops strategies to manage workload, quality of reviews and process improvements.

 

Responsibilities:

 

Lead and mentor a team certified coders who support fraud detection and prevention efforts.

Establish team goals, monitor performance, and ensure alignment with organizational objectives.

Direct and oversee complex reviews. 

Ensure timely and accurate reporting of review findings and coordinate with investigative to take appropriate action. 

Conducts team member evaluations and provides performance feedback to staff on an ongoing basis.

Manages workload of their team to ensure equitable distribution and exposure to wide range of cases to match current skills and development needs

Confirm staff are preparing comprehensive reports summarizing investigation outcomes.

Ensure findings comply with state, federal, and industry regulations. 

Stay informed about changes in the industry practices related to healthcare coding. 

Provide training opportunities for staff to maintain their CEUs.

Assist in preparing documentation for audits, compliance reviews, and regulatory inquiries.

Required Qualifications:

Minimum 5+ years of experience in healthcare fraud detection, investigation, or auditing

In-depth knowledge of healthcare systems, claims processing, and regulatory requirements related to healthcare fraud.

Proficient in researching information and identifying information resources

AAPC Coding certification - Certified Professional Coder (CPC)

Strong leadership and team management ability

Excellent communication and presentation skills.

Ability to work cross-functionally with various teams and external partners.

Ability to travel for business needs.

 

 

Preferred Qualifications:

Registered Nurse (RN)

Previous leadership experience. 

AAPC Coding Certification – Certified Professional Biller (CPB), Certified Professional Medical Auditor (CPMA), Certified Outpatient Coder (COC), Certified Risk Adjustment Coder (CRC)

Licensed Clinical Social Worker (LCSW)

Licensed Independent Social Worker (LISW)

Licensed Master Social Worker (LMSW)

Education
Bachelor, Associates Degree or work equivalent

Certification as a Certified Professional Coder (CPC)

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$54,300.00 - $159,120.00

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. 
 
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, de