We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
Position Summary
Responsible for conducting complex audits, reviews and assessments of medical records coded by internal teams prior to the submission to the Centers of Medicare and Medicaid Services (CMS) for the purpose of risk adjustment processes are appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and procedures. Contributes to compliance reporting and documentation, highlighting findings, recommendations, and areas of concern to be delivered to coding resources.
Demonstrated ability to apply coding judgment and make decisions using industry-standard evidence and tools, exercising independent judgment to determine final outcomes prior to submission with minimal supervision.
Adhere to stringent timelines consistent with project deadlines and directives.
Demonstrates a strong commitment to enhancing and promoting quality; consistently delivers accurate and thorough work, and supports others in achieving the same standards through effective mentoring and instruction.
Serves as the training resource and subject matter expert to vendors, providers and other team members for questions regarding ICD coding and documentation requirements.
Comprehensive knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity.
Identify and communicate documentation deficiencies to allow for continuous education opportunities for providers, vendors, and peers.
Expertise in medical documentation, fraud, abuse and penalties for documentation and coding violations based on governmental guidelines.
Evidenced knowledge of problem solving and decision making skills.
Acts as mentor to provide education to internal staff based on audit findings; provides general education on ICD codes as appropriate.
Communicates with corporate legal and compliance teams to ensure accurate and timely reporting to external authorities.
As the need arises, may liase with regulatory bodies, auditors, and legal professionals to address compliance-related matters.
Required Qualifications
- Minimum of 5 years recent and related experience in medical record documentation review, diagnosis coding, and/or auditing.
- Experience with Medicare and/or Commercial and/or Medicaid Risk Adjustment process and Hierarchical Condition Categories (HCC) required.
- Completion of AAPC/AHIMA training program for core credential (CPC, CCS-P) with associated work history/on the job experience equal to approximately 5 years for CPC.
- CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) and CRC (Certified Risk Adjustment Coder) required.
- CPMA (Certified Professional Medical Auditor) or CDEO (Certified Documentation Expert Outpatient) preferred.
Preferred Qualifications
- Computer proficiency including experience with Microsoft Office products (Word, Excel, Access, PowerPoint, Outlook, industry standard coding applications).
- Experience with International Classification of Disease (ICD) codes required.
- Experience with Medicare and/or Commercial and/or Medicaid Risk Adjustment process and Hierarchical Condition Categories (HCC) required.
- Expertise in medical documentation, fraud, abuse and penalties for documentation and coding violations based on governmental guidelines.
Education
- Bachelor's degree preferred
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$46,988.00 - $112,200.00This 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.
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 https://jobs.cvshealth.com/us/en/benefits
We anticipate the application window for this opening will close on: 03/13/2026Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
