Program Integrity Auditor

Job not on LinkedIn

🕒 5 days ago

🌵 Arizona – Remote

🌵 Arizona – Remote

💵 $47k - $122.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

⚕️ Healthcare Insurance

🛒 Retail

🧘 Wellness

Healthcare Insurance • Retail • Wellness

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Serve as an audit team member for a health plan(s) which currently administers benefits to Medicaid members across multiple lines of business including acute, behavioral health, individuals with developmental disabilities, and children in out-of-home care • Audit records on a routine basis, as well as records for audits (requested on an ad hoc basis) for all lines of business, in order to ensure coding and documentation meet regulatory standards • Coordinate audit documentation and reports for review for internal and external staff and stakeholders • Identify aberrant billing patterns and potential FWA, reporting this to internal staff • Assisting with further investigation and/or reports to state regulators through the utilization of developed critical thinking skills • Assist with the development and implementation plan for prospective and retrospective FWA avoidance, detection, and referral • Assist with the creation and submission of regulator deliverables through completion of timely audit activities • Provide technical assistance and education to providers including training on regulatory requirements, as well as coding and documentation rules • Maintain compliance with company policies and procedures • Perform other duties as assigned.

🎯 Requirements

• 3-5 years of experience in reviewing and interpreting claims data • 3-5 years of experience with standard industry coding guidelines such as CPT, HCPCs, and ICD-10 • Willingness to work Monday-Friday from 8am-5pm Arizona Time Zone • Must possess an active CPC ( Certified Professional Coder ), CCS ( Certified Coding Specialist ), or CPMA ( Certified Professional Medical Auditor ) license • Previous auditing experience • Previous Medicaid and/or health plan experience, including AHCCCS ( Arizona Health Care Cost Containment System ) • Previous experience with QuickBase • Strong analytical and critical thinking skills • Strong attention to detail • Ability to collaborate and work with a team, as well as work independently as needed • Excellent presentational skills • Strong communication skills, both written and verbal • Ability to be adaptable in a flexible environment.

🏖️ Benefits

• medical, dental, and vision coverage • paid time off • retirement savings options • wellness programs • comprehensive benefits package