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.Position Summary:
The Senior Clinical Investigator Consultant will support Medical Cost Management Solutions team which is an integral component to delivering on the total cost of care. This role supports review of self-insured plans for our Meritain TPA business. This role will work within the Special Investigations Unit, while also working with various stakeholder groups within the broader organization and external vendors.
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The candidate will review provider medical records using coding criteria, state guidelines, and company policies for clinical appropriateness. Prepare a summary of findings to recommend next steps, including prepayment review, post payment review, and draft provider corrective action plans. Identify preemptive measures to prevent further fraudulent billing practices/schemes and manage complex investigations into suspected fraud, waste, and abuse (FWA).
- Conduct a comprehensive medical record audit to ensure the CPT/HCPCS or modifiers billed are consistent with medical record documentation.
- Handles complex coding reviews and provide detailed written summary of medical record review findings.
- Must be able to articulate findings to investigators, law enforcement, legal counsel.
- Review and discuss cases with Medical Directors
- Independently research and accurately apply state or CMS guidelines related to the audit.
- Assist with investigative research related to coding questions, state, and federal policies.
- Identify opportunities for savings related to potential cases which may warrant a prepayment review.
- Maintain appropriate records, files, documentation, etc.
- Mentor teammates, providing training, coding, and record review guidance.
- Collaboration with investigators, data analytics and plan leadership on SIU schemes.
- Conduct high level, complex investigations of known or suspected acts of healthcare fraud, waste, and abuse.
- Documents all appropriate case activity in case tracking system.
- Prepare written case summaries and make referrals to State and Federal Agencies within the timeframes required by Law.
- Provide Trial Testimony in support of Criminal or Civil proceedings.
- Act as management back-up and supports the team when the manager is out of the office.
- 5+ years' experience in the HealthCare Industry conducting medical review/claim audit (Claims/Coding/Edit Development, medical reimbursement policy development)
- Command of Coding, edits, standard software edits, Facility and Professional formatted claim submissions
- Familiarity with Fraud, Waste and Abuse schemes within the HealthCare Industry
- Ability to apply ICD coding, CPT coding, have knowledge of CMS regulations.
- Project work, or Business Analysis background with recognized teamwork skills and demonstrated success.
- Strong communication skills with a broad range of individuals and groups, including members and provider.
- Data Management skills with ability to evaluate, as well as generate, reports as needed-an analytical and statistical background.
- CPC Coding Certificate or equivalent
- Nursing degree
- RN license
The typical pay range for this role is:$67,900.00 - $190,344.00
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. This position also includes an award target in the company's equity award program.
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, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off ("PTO") or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.
For more detailed information on available benefits, please visit Benefits | CVS HealthWe anticipate the application window for this opening will close on: 03/13/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.