Certified Professional Coder, Special Investigations Unit (Aetna SIU)

Description

CVS Health’s Aetna Special Investigations Unit (SIU) is hiring Certified Professional Coders to support efforts to identify and address health care fraud, waste, and abuse. The role centers on reviewing medical claims and records to determine whether coding and documentation are accurate and compliant with applicable requirements.

The Certified Professional Coder will conduct detailed medical record reviews covering areas such as medical, behavioral health, transportation, and other healthcare providers. The work involves checking CPT, HCPCS, modifiers, ICD-10, and documentation against what was actually billed and identifying unusual billing patterns or potential compliance concerns.

This is a strong fit for an experienced medical coder or documentation auditor who already holds an AAPC Certified Professional Coder (CPC) certification. Candidates should be comfortable researching coding policies, analyzing records, writing detailed findings, and communicating conclusions to investigators and other stakeholders.

Job at a Glance

Job Title	Certified Professional Coder, Special Investigations Unit (Aetna SIU)
Company	CVS Health / Aetna
Location	Remote
Job Type	Full-Time
Experience	3+ years of medical coding or documentation auditing experience
Industry	Health Care / Health Insurance
Job Category	Medical Coding / Special Investigations
Main Focus	Medical claim review, coding compliance, documentation auditing, and fraud, waste and abuse support
Salary	$43,888–$93,574 per year

Detailed Role Requirements & Responsibilities

Medical Claim and Record Review

The core responsibility is reviewing medical claims and supporting records to determine whether the coding accurately reflects the documentation.

You will:

• Conduct comprehensive medical record reviews
• Compare billed services with medical record documentation
• Review CPT and HCPCS codes
• Review modifiers
• Determine whether the documentation supports the codes billed
• Identify coding or documentation concerns
• Check whether applicable requirements are being met

Strong knowledge of medical coding guidelines is essential because the role requires making informed decisions based on both the claim and supporting documentation.

Coding Compliance

The CPC will help ensure that coding practices comply with industry, state, federal, and company requirements.

The work includes:

• Applying CPT coding guidelines
• Applying HCPCS coding guidelines
• Applying ICD-10 coding guidelines
• Reviewing CMS-1500 data elements
• Reviewing UB-04 data elements
• Researching coding policies
• Keeping coding knowledge current
• Identifying potential compliance issues

The ability to keep up with changes in coding and reimbursement requirements is particularly important in this position.

Fraud, Waste and Abuse Review

The SIU focuses on healthcare fraud, waste, and abuse. The coding role supports these investigations by identifying billing or documentation patterns that may require additional review.

You may be expected to:

• Recognize concerning billing patterns
• Identify unusual coding trends
• Review claims for potential irregularities
• Provide information that can support an investigation
• Assist with investigative research
• Help validate coding-related findings

This means the role goes beyond routine claims coding and requires analytical thinking.

Written Findings and Documentation

After reviewing records, the CPC must be able to clearly document the results.

Responsibilities include:

• Preparing detailed written summaries of findings
• Maintaining appropriate records and files
• Documenting review activities
• Clearly explaining coding concerns
• Providing information that investigators can use during an investigation

Strong writing skills are therefore important, particularly when explaining technical coding findings to people who may not have the same coding background.

Collaboration With Investigators and Other Professionals

The position involves communicating findings to a range of stakeholders.

Depending on the investigation, findings may need to be communicated to:

• SIU investigators
• Medical Directors
• Medicaid plan leadership
• Legal counsel
• Law enforcement
• Healthcare providers
• State regulators

The ability to explain coding decisions clearly and professionally is an important part of the role.

Research and Policy Review

The CPC will research coding questions and applicable policies when needed.

This includes:

• Researching coding guidelines
• Reviewing state and federal policies
• Researching reimbursement requirements
• Investigating questions related to documentation and coding
• Keeping knowledge current as coding rules change

Productivity and Independent Work

The position requires the ability to use department resources and established workflows with limited assistance.

The CPC is expected to:

• Follow established workflows
• Complete daily work according to performance metrics
• Work independently
• Maintain accurate records
• Manage review assignments efficiently
• Ask for assistance when appropriate

Required Skills and Experience

The main requirements include:

• AAPC Certified Professional Coder (CPC) certification
• 3+ years of experience in medical coding or documentation auditing
• Knowledge of CPT
• Knowledge of HCPCS
• Knowledge of ICD-10
• Knowledge of CMS-1500 data elements
• Knowledge of UB-04 data elements
• Experience researching coding and healthcare policies
• Experience with Microsoft Word
• Experience with Microsoft Excel

The CPC certification is particularly important because it is explicitly listed as a required qualification.

Skills That Can Strengthen Your Application

The following qualifications can make an application stronger:

• Previous medical auditing experience
• Strong analytical skills
• Strong attention to detail
• Experience interpreting large amounts of healthcare data
• Strong written communication
• Strong verbal communication
• Behavioral health coding experience
• Behavioral health auditing experience
• Experience supporting fraud, waste, and abuse investigations
• Experience researching state and federal healthcare policies
• Experience working with Medical Directors
• Experience working with legal or regulatory teams
• Advanced Microsoft Excel skills

CVS Health specifically identifies two or more years of behavioral health coding or auditing experience as a preferred qualification.

Industry Context & Career Advice

Medical coding is increasingly connected to compliance, auditing, reimbursement accuracy, and healthcare fraud prevention. A coder working in an SIU environment needs to understand not only whether a code is technically correct, but also whether the documentation supports the billed service and whether billing patterns raise additional concerns.

Aetna’s SIU specifically includes coding, investigations, and quality functions as part of its efforts to address healthcare fraud, waste, and abuse.

For someone building a career in this area, medical auditing, compliance, behavioral health coding, and fraud investigation experience can provide useful opportunities for career development. Strong knowledge of coding updates is also important because reimbursement and coding requirements can change.

When applying, avoid presenting yourself only as someone who enters or assigns codes. This position requires review, interpretation, research, analysis, documentation, and communication. Your resume should show that broader skill set.

What to Highlight on Your Resume

For this position, make the following qualifications highly visible:

• AAPC CPC certification
• 3+ years of medical coding experience
• Documentation auditing
• Medical record review
• CPT
• HCPCS
• ICD-10
• CMS-1500
• UB-04
• Coding compliance
• Medical claims review
• Coding policy research
• Reimbursement knowledge
• Fraud, waste and abuse
• Healthcare auditing
• Behavioral health coding
• Behavioral health auditing
• Microsoft Excel
• Microsoft Word
• Analytical skills
• Written reporting
• Compliance research
• Attention to detail
• Communication with investigators and other stakeholders

Where possible, quantify your experience. For example, mention the number or types of records reviewed, the types of providers audited, or measurable improvements in coding accuracy.

A stronger resume bullet could be:

Conducted comprehensive medical record and claims reviews to validate CPT, HCPCS, ICD-10 codes and modifiers against documentation, identified coding discrepancies, and prepared detailed findings for compliance and investigative review.

Customize this bullet with your actual experience and results rather than copying it word for word.

Interview Preparation

How do you determine whether a billed code is supported by medical documentation?

Be prepared to explain how you review the record, compare documentation with billed services, apply coding guidelines, and determine whether the coding is appropriate.

How do you approach a medical coding audit?

Explain your process from receiving the records through reviewing documentation, checking codes and modifiers, researching guidelines, documenting findings, and communicating the results.

What is the difference between CPT, HCPCS, and ICD-10?

Review the purpose of each coding system and be ready to explain how they work together during claims review.

How do you stay current with coding changes?

Discuss the professional resources, coding guidelines, training, publications, or other methods you use to stay informed about changes affecting coding and reimbursement.

What would you do if you noticed an unusual billing pattern?

Explain how you would document the observation, research the applicable requirements, verify the information, and communicate the concern through the appropriate investigative process.

How do you communicate complex coding findings to someone without a coding background?

This is particularly important because the role may involve communication with investigators, legal counsel, regulators, providers, and other stakeholders. Focus on using clear language while preserving the technical accuracy of your findings.

Tell us about a difficult audit you completed.

Choose an example that demonstrates attention to detail, research, analytical thinking, and the ability to reach a defensible conclusion.

How do you manage a high volume of review work?

Explain how you organize cases, prioritize assignments, follow established workflows, maintain accuracy, and meet productivity expectations.

What experience do you have with behavioral health coding?

If applicable, discuss the types of records you reviewed, coding systems used, audit responsibilities, and any issues you regularly encountered.

Advice for Applicants

This position is aimed at an experienced medical coding professional, so the CPC certification and 3+ years of medical coding or documentation auditing experience should be among the first qualifications recruiters see on your resume.

If you have auditing experience, do not hide it under a general “Medical Coder” job title. Explain that you reviewed medical records, compared documentation with claims, researched coding policies, identified discrepancies, and prepared written findings.

Behavioral health coding or auditing experience can also help distinguish your application because CVS Health lists two or more years of this experience as preferred.

This role is also different from a routine production coding position. The SIU environment places greater emphasis on compliance, investigation support, analytical review, unusual billing patterns, and clear communication of findings. Candidates should therefore position themselves as medical coding professionals who can investigate and explain discrepancies, not simply assign codes.

The strongest application will show that you can review complex medical records, apply coding guidelines accurately, identify potential compliance concerns, document your findings clearly, and communicate technical conclusions to investigators and other stakeholders.

Benefits

CVS Health states that eligible full-time colleagues receive a comprehensive benefits package that can include:

• Medical coverage
• Dental coverage
• Vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources supporting physical, emotional, and financial well-being

The position is listed as full-time with an anticipated schedule of 40 hours per week.