Senior Special Investigations Coding Manager (Aetna SIU)

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

We are seeking an experienced medical professional to manage strategic initiatives, along with a team of medical coders/nurses supporting Aetna's Special Investigations Unit.Key Responsibilities:

• Leadership: Leads a team of coding/nursing professionals who conduct reviews of medical records and claims for suspected healthcare fraud, waste, and abuse. Provides direction and counsel to support coders and progress reviews. Identification and implementation of key initiatives that support effective and efficient scalability along with meeting or exceeding ROI.

• Team Management: Conducts team member evaluations and provides performance feedback to staff. Manages team's caseload to ensure equitable distribution and exposure to wide range of reviews. Assist with business opportunities aligned to inventory allocation and prioritization.

• Quality Control and Compliance: Maintains oversight of coder/nurse reviews, ensuring compliance with ICD-10, CPT and HCPCS coding guidelines. Assist with department build and implementation of SIU coding quality program.

• Training: Assesses team's training needs and works with SIU leadership on development plans for team members and SIU coding department. Contributes to the development and delivery of educational awareness and training programs that meet or exceed those required by state mandates. Coordinates ongoing trainings to educate team on updates or modifications to medical codes.

• Presentations: Supports the team of coding/nursing professionals in presenting findings to internal and external stakeholders, including, but not limited to SIU Investigators, Aetna Plan Leadership, Law Enforcement, Legal Counsel, Providers, and State Regulators.

• Collaboration: Develops and maintains close working relationships with Aetna Medical Directors, Nurses, and other clinical staff who conduct medical record reviews. Consults with clinical staff as needed to assist in reviews. Partnership with SIU leadership to deliver key initiatives dedicated to infrastructure build and stabilization.

• Minimum of 8 years of experience in medical coding in an SIU setting with at least 5 years in a supervisory or management role.
• Strong knowledge of industry coding guidelines involving ICD-10, CPT and HCPCS codes.
• Ability to guide a team of coding professionals with differing levels of coding experience in a variety of medical specialties.
• Proficiency in Microsoft products including, but not limited to Word, Excel, Outlook, and PowerPoint.
• Experience in infrastructure build and design to include, but not limited to workforce modeling, efficiency identification and implementation resulting in demonstrated decrease in unit cost, inventory reporting, inventory allocation for Medicare, Medicaid and Commercial (fully insured and ASO) work product, development of standardized coding language, assist with operational dashboard development and execution of department action plans.
• Understanding of how to implement SIU coding quality programs, to include statistical sampling, IRR testing, building objective comprehension assessments for coding training and coding quality remediation plans.
• Ability to communicate to a wide range of stakeholders, adjusting the message as appropriate for the recipient(s).
• Proven experience in overseeing and executing operational projects.
• Potential to travel up to 10%, (dependent on business needs).

• Active Registered Nurse (RN) Licensure preferred
• Experience conducting audits of medical records to substantiate allegations of healthcare fraud, waste, and abuse.
• Experience leading a team of coding professionals who conduct reviews to substantiate allegations of healthcare fraud, waste, and abuse.
• Experience with Aetna or other MCO Commercial/Medicaid/Medicare plans
• Certified Professional Coder

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

• 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.