Program Integrity Auditor

Job not on LinkedIn

🕒 July 31

🌵 Arizona – Remote

🌵 Arizona – Remote

💵 $47k - $122.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

👻 Ghost score 42%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

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

• Review records for medical, behavioral, transportation, and other healthcare providers • Determine correct coding and appropriate documentation during medical record reviews • Audit provider records to ensure coding and documentation standards are met • Recommend follow-up actions including provider education, recoupment of funds, rebilling of claims, and referral to state regulators for suspected fraud, waste, or abuse • Serve as an audit team member for health plans administering Medicaid benefits across multiple lines of business • Conduct routine and ad hoc audits across all lines of business • Coordinate audit documentation and reports for internal and external staff and stakeholders • Identify aberrant billing patterns and potential fraud, waste, and abuse and report findings to internal staff • Assist with investigations and reports to state regulators • Assist with developing and implementing prospective and retrospective FWA avoidance, detection, and referral plans • Assist with creation and submission of regulator deliverables through timely audit activities • Provide technical assistance and education to providers on regulatory requirements, coding, and documentation rules • Maintain compliance with company policies and procedures • Perform other duties as assigned

🎯 Requirements

• 3-5 years of experience reviewing and interpreting claims data, medical records, and appropriate documentation • 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 • Associate’s degree or equivalent experience (2+ years of relevant experience + high school diploma or GED) • Previous auditing experience preferred • Previous Medicaid and/or health plan experience, including AHCCCS preferred • Previous experience with QuickBase preferred • 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 written and verbal communication skills • Ability to be adaptable in a flexible environment

🏖️ Benefits

• CVS Health bonus, commission or short-term incentive program in addition to base pay • Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being, based on eligibility