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

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.

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.

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. 
 

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.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits – investing