Job Description

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. **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. 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. **Required Qualifications:** + 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. **Preferred:** + Data Management skills with ability to evaluate, as well as generate, reports as needed-an analytical and statistical background. **Education:** + CPC Coding Certificate or equivalent + Nursing degree + RN license **Pay Range** 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. 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 in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: + **Affordable medical plan options,** a **401(k) plan** (including matching company contributions), and an **employee stock purchase plan** . + **No-cost programs for all colleagues** including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. + **Benefit solutions that address the different needs and preferences of our colleagues** including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit We anticipate the application window for this opening will close on: 04/30/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Job Tags

Hourly pay, Full time, Temporary work, Work at office, Local area, Flexible hours,

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