Manager, W&E Professional Coding

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The Waste & Error Certified Coding Manager is responsible for leading the Certified Coding Analyst and W&E Team Lead roles that conduct medical claim reviews and coding audits to identify billing errors waste abuse fraud and payment integrity opportunities. The Manager provides direct people leadership establishes operational priorities ensures consistent application of coding and billing requirements and is accountable for team productivity quality service levels compliance and employee development.

This role partners closely with the W&E team lead who provides day-to-day technical guidance and subject matter support to the coding team. The Manager retains accountability for staffing performance management workload oversight escalations audit readiness process improvement and delivery of business outcomes. The position also represents the team in discussions with senior leadership Medical Directors Legal Compliance Analytics Operations and other Payment Integrity partners.

• Lead coach and develop a team of Certified Coding Analysts and Senior Certified Coding Analysts.
• Establish clear role expectations performance goals productivity standards quality requirements and accountability measures.
• Conduct regular performance discussions provide timely feedback recognize strong performance and address performance or conduct concerns.
• Oversee hiring onboarding training succession planning engagement and retention for the coding team.
• Deliver technical coaching peer support quality remediation and ongoing education.
• Create an inclusive collaborative team environment that promotes knowledge sharing sound judgment and continuous learning.

• Provide operational oversight for medical record reviews coding audits (Initial review reconsiderations & appeals) and related waste and error activities performed by the coders.
• Assign priorities and manage work queues to ensure production turnaround time quality and service level expectations are met.
• Monitor workload staffing capacity inventory aging and productivity trends; adjust assignments and resources as needed.
• Ensure analysts conduct comprehensive reviews and accurately apply CPT HCPCS ICD-10 modifier CMS state federal and organizational requirements.
• Oversee escalation pathways for complex coding questions policy interpretation Medical Director review and case decisions.
• Ensure case findings and decision rationales are clear complete consistently documented and supportable.
• Perform other duties as assigned.

• Establish and monitor quality review processes for coding audit work completed by the team.
• Review quality results identify performance gaps and implement targeted coaching training or corrective action plans.
• Ensure consistent application of coding guidelines reimbursement requirements business rules workflows and documentation standards.
• Maintain adherence to state federal contractual accreditation and organizational requirements.
• Partner with Legal Compliance Medical Directors and other subject matter experts to resolve complex or high-risk issues.
• Support internal audits external audits regulatory reviews and documentation requests.

• Develop and monitor key performance indicators for productivity quality inventory turnaround time savings and operational outcomes.
• Analyze team performance coding trends recurring billing issues and root causes to identify improvement opportunities.
• Prepare and present operational updates performance results risks decisions and recommendations to leadership and business partners.
• Drive process standardization workflow improvements automation system enhancements and effective use of department resources.
• Participate in system implementations upgrades pilots and new program launches affecting coding audit operations.
• Use audit findings and trend data to support provider education policy clarification analyst development and prevention strategies.

• Collaborate with Senior Leadership Medical Directors Legal Compliance Analytics Operations Technology and Payment Integrity partners.
• Serve as the management escalation point for complex cases operational barriers coding disputes and stakeholder concerns.
• Communicate difficult or sensitive operational issues clearly objectively and with recommended solutions.
• Build alignment across partners while protecting coding accuracy regulatory compliance provider experience and business objectives.
• Represent the Waste & Error coding team in governance meetings business reviews implementation activities and strategic initiatives.

• Active AAPC Certified Coder CPC CCS RHIT or RN license w/significant coding/ auditing experience may be considered.
• 5 years of experience in medical coding claims review auditing payment integrity fraud waste abuse or error review.
• 2 years of people leadership supervisory or team management experience including performance management coaching and employee development.
• Experience leading coding quality programs productivity management workload oversight and targeted remediation activities.
• Strong knowledge of CPT HCPCS ICD-10 CMS 1500 UB-04 coding compliance and reimbursement requirements.
• Experience researching and applying state federal CMS and organizational policies.
• Demonstrated ability to manage multiple priorities resolve complex issues and meet operational deadlines.
• Strong written and verbal communication skills including the ability to present performance results and case decisions to internal and external stakeholders.
• Proficiency with Microsoft Excel and Word; ability to interpret operational and quality data.

• Experience with Medicaid auditing rules and regulations
• Experience with reconsiderations and appeals for institutional and professional claim reviews.
• Prior experience in fraud waste abuse and error Payment Integrity or healthcare audit operations.
• Experience partnering with Medical Directors Legal Compliance Analytics and senior leadership.
• Experience with process improvement system implementations operational reporting and change management.
• EncoderPro or comparable coding research tool experience.

We support a hybrid work environment. If selected and you live near a suitable work location you may be expected to comply with the hybrid work policy. Under the policy all hires for in-scope populations should be placed into a hybrid or office-based location working onsite three days a week.

Aetna Service Operations office/hub locations will be discussed with the selected candidate.

High school diploma or GED.

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Additional details about available benefits are provided during the application process and on Benefits Moments.

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