Behavioral Health Coding Auditor
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Job Location:
Monthly Salary:
Experience Required:
Posted on:
30+ days ago
Vacancies:
1 Vacancy
Job Summary
This is a remote position.
Behavioral Health Coding Auditor (Consultant)
Overview
Were seeking a Certified Medical Coder with deep Behavioral Health expertise to audit current coding practices and outcomes for a healthcare payer organization. The consultant will assess provider-facing coding (CPT HCPCS ICD-10) in the Behavioral Health domain identify issues and recommend rule definitions and process improvements to optimize accuracy and reimbursement. Experience configuring payer platformsespecially HealthEdge HealthRules or Optum equivalentsis a strong plus.
What Youll Do
Audit & Analysis
Perform retrospective and prospective audits of Behavioral Health claims and encounters (CPT/HCPCS/ICD-10).
Evaluate accuracy completeness and adherence to payer and Medicaid guidelines with emphasis on Rhode Island Medicaid policy requirements.
Analyze denial trends under/overpayments edits and provider coding patterns; quantify impact and root causes.
Policy & Rule Recommendations
Draft clear actionable coding rule definitions and edit logic recommendations (e.g. medical necessity bundling/unbundling frequency limits).
Align recommendations to CMS/NCCI state Medicaid policy and payer policy; highlight provider education needs.
Implementation Support (Preferred)
Collaborate with configuration/benefits/claims ops teams to translate recommendations into system configuration and edits.
Validate changes through test claims UAT scenarios and pre/post implementation measurement.
Provider & Stakeholder Engagement
Create concise audit reports dashboards and provider feedback packets.
Support provider education sessions and internal stakeholder workshops.
Outcome Measurement
Define KPIs (accuracy rate first-pass adjudication denial reduction net financial impact) and build a lightweight tracking plan.
Deliverables (Sample)
Audit Plan & Baseline Report (weeks 13): scope sampling methods baseline accuracy/denial metrics.
Findings & Recommendations Deck (weeks 48): prioritized issues with quantified impact policy references and rule definitions.
Configuration & UAT Support (weeks 816 if engaged): configuration specs test scripts UAT sign-offs.
Provider Education Materials (as needed): coding tip sheets documentation checklists.
Final Outcomes Report (end of engagement): pre/post metrics net financial impact sustainment plan.
Success Metrics
Improvement in coding accuracy and first-pass adjudication rates.
Reduction in avoidable denials and rework.
Measurable net financial impact (under/overpayment correction leakage reduction).
Clear adoptable rules and provider guidance; successful UAT and production outcomes (if configuration support is in scope).
Engagement Details
Type: 1099 or C2C contract (6 months extension possible).
Hours: Full-time preferred; part-time considered with strong fit.
Work Setup: Remote; occasional meetings during Eastern Time business hours.
Requirements
Must-Have Qualifications
Active coding certification: CPC CCS RHIT RHIA or equivalent.
Behavioral Health depth: Proven experience auditing and coding across outpatient/inpatient behavioral health services (e.g. psychotherapy psychiatry services IOP/PHP MAT SUD).
Code sets & guidelines: Advanced proficiency in CPT HCPCS and ICD-10 with provider-side interpretation and payer-side application.
Medicaid expertise: Hands-on experience with Medicaid programs and policy; familiarity with Rhode Island Medicaid requirements and documentation standards.
Payer environment: Background working with health plans/TPAs on claims adjudication policy and edits.
Analytical & communication skills: Ability to turn audit findings into crisp recommendations and present them to technical and non-technical audiences.
Tools: Strong Excel/Sheets; comfort with claims data extracts and basic BI/reporting.
Nice-to-Have
Platform experience: HealthEdge HealthRules (benefits configuration claims edits accumulators) or Optum payer platforms (e.g. Claims Edit System Optum CES payment integrity tools).
Configuration skills: Ability to translate policy into configuration specs and participate in build/UAT.
Payment integrity knowledge: Familiarity with NCCI edits prior authorization linkages medical necessity policies and documentation requirements.
Provider education: Experience delivering coding education and remediation plans to provider groups.
Required Skills:
Active coding certification: CPC CCS RHIT RHIA or equivalent. Behavioral Health depth: Proven experience auditing and coding across outpatient/inpatient behavioral health services (e.g. psychotherapy psychiatry services IOP/PHP MAT SUD). Code sets & guidelines: Advanced proficiency in CPT HCPCS and ICD-10 with provider-side interpretation and payer-side application. Medicaid expertise: Hands-on experience with Medicaid programs and policy; familiarity with Rhode Island Medicaid requirements and documentation standards. Payer environment: Background working with health plans/TPAs on claims adjudication policy and edits. Analytical & communication skills: Ability to turn audit findings into crisp recommendations and present them to technical and non-technical audiences. Tools: Strong Excel/Sheets; comfort with claims data extracts and basic BI/reporting.
Required Education:
HS Diploma or equivalent work experience.
Company Industry
IT Services and IT Consulting
Key Skills
- Auditing
- Time Management
- ICD-10
- Accounting
- Component evaluation
- Workers' Compensation Law
- SOX
- Microsoft Excel
- CPT Coding
- Internal Audits
- Medicare
- Bookkeeping
