Special Investigation Unit (SIU) Coding Review Manager

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 Certified Professional Coder (CPC) Manager will oversee a team of medical coders within the Special Investigations Unit (SIU) to ensure compliance with coding practices through comprehensive record reviews for medical, behavioral, transportation, and other healthcare providers. The CPC Manager will be responsible for guiding the team in determining correct coding and appropriate documentation during the review of medical records. This role requires a strong focus on meeting state, federal, and company requirements while identifying concerning billing patterns or trends.

• Lead and mentor a team of CPCs, providing training, guidance, and support in coding practices and medical record reviews.
  
• Conduct regular audits of team performance to ensure compliance with CPT/HCPCS coding and documentation standards.
  
• Establish team goals, monitor performance, and ensure alignment with organizational objectives.
  
• Direct and oversee complex coding reviews and resolve intricate issues with sensitivity, including claim reviews for legal, compliance, or rework projects.
  
• Ensure staff provide detailed written summaries of medical record review findings and ensure the team articulates findings effectively to investigators, Medicaid plan leadership, law enforcement, legal counsel, providers, and state regulators.
  
• Conducts team member evaluations and provides performance feedback to staff on an ongoing basis.
  
• Collaborate with Medical Directors to validate decisions and discuss complex cases.
  
• Manages workload of their team to ensure equitable distribution and exposure to wide range of cases to match current skills and development needs.
  
• Assist with investigative research related to coding questions, state and federal policies, and identify potential billing errors, abuse, and fraud.
  
• Identify opportunities for savings related to potential cases that may warrant a prepayment review.
  
• Maintain appropriate records, files, and documentation for the team.
  
• Utilize department resources effectively and ensure workflows are followed to meet performance metrics.
  
• Collaborate with investigators, data analytics, and plan leadership on SIU schemes and initiatives.
  
• Act as the primary point of contact for the team in the absence of the director, ensuring continuity of operations and support.
  
• Develop and implement training and onboarding programs for new team members.
  

• A minimum of 2 years of managing a staff.
  
• Coding Certification (CPC, CPMA, COC).
  
• A minimum of 5 years of experience in medical record review for coding accuracy.
  
• Strong knowledge of standard industry coding guides and guidelines, including CPT, HCPCS, ICD-10, CMS 1500, and UB04 data elements.
  
• Maintains up-to-date coding knowledge, including new changes to coding compliance and reimbursement.
  
• Experience with researching coding and policies.
  
• Proficiency in Microsoft products, particularly Excel and Word.
  
• Strong attention to detail and ability to review and interpret data.
  
• Demonstrates strong communication and leadership skills.
  

• A minimum of 2 years of managing staff within a Special Investigation Unit (SIU).
  
• Excellent analytical skills and the ability to mentor and develop team members.
  
• Registered Nurse (RN).
  
• Previous experience with Behavioral Health coding/auditing of records.
  

• Bachelor�s degree preferred or a combination of education and professional work experience.
  

40

Full time

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.

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 https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 09/06/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.