Program Integrity Auditor

CVS Health

Program Integrity Auditor reviewing and auditing provider records to ensure appropriate coding standards. Ensuring compliance with regulations while supporting Medicaid members across multiple lines of business.

Posted 5/27/2026full-timeRemote • Arizona • 🇺🇸 United StatesMid-LevelSenior💰 $46,988 - $122,400 per yearWebsite

About the role

Key responsibilities & impact

Serve as an audit team member for a health plan(s) which currently administers benefits to Medicaid members across multiple lines of business including acute, behavioral health, individuals with developmental disabilities, and children in out-of-home care.
Audit records on a routine basis, as well as records for audits (requested on an ad hoc basis) for all lines of business, in order to ensure coding and documentation meet regulatory standards.
Coordinate audit documentation and reports for review for internal and external staff and stakeholders.
Identify aberrant billing patterns and potential FWA, reporting this to internal staff.
Assisting with further investigation and/or reports to state regulators through the utilization of developed critical thinking skills.
Assist with the development and implementation plan for prospective and retrospective FWA avoidance, detection, and referral.
Assist with the creation and submission of regulator deliverables through completion of timely audit activities.
Provide technical assistance and education to providers including training on regulatory requirements, as well as coding and documentation rules.
Maintain compliance with company policies and procedures.
Perform other duties as assigned.

Requirements

What you’ll need

3-5 years of experience in reviewing and interpreting claims data, as well as medical records and appropriate documentation.
3-5 years of experience with standard industry coding guidelines such as CPT, HCPCs, and ICD-10.
Willingness to work Monday-Friday from 8am-5pm Arizona Time Zone.
Must possess an active CPC ( Certified Professional Coder ), CCS ( Certified Coding Specialist ), or CPMA ( Certified Professional Medical Auditor ) license.
Previous auditing experience.
Previous Medicaid and/or health plan experience, including AHCCCS ( Arizona Health Care Cost Containment System ).
Previous experience with QuickBase.
Strong analytical and critical thinking skills.
Strong attention to detail.
Ability to collaborate and work with a team, as well as work independently as needed.
Excellent presentational skills.
Strong communication skills, both written and verbal.
Ability to be adaptable in a flexible environment.

Benefits

Comp & perks

medical, dental, and vision coverage
paid time off
retirement savings options
wellness programs
other resources, based on eligibility

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

claims data reviewmedical records interpretationCPT codingHCPCs codingICD-10 codingaudit documentationbilling pattern analysisFWA detectionregulatory complianceaudit reporting

Soft Skills

analytical skillscritical thinkingattention to detailcollaborationindependencepresentational skillscommunication skillsadaptability

Certifications

CPCCCSCPMA