Behavioral Health Coding Auditor

Job Description

Job Description

This is a remote position.

Behavioral Health Coding Auditor (Consultant)
Engagement: ~6 months (contract)
Location: Remote (U.S.)
Industry: Healthcare Payer (Medicaid focus – Rhode Island)
Overview

We’re 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 platforms—especially HealthEdge HealthRules or Optum equivalents—is a strong plus.

What You’ll 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 1–3): scope, sampling, methods, baseline accuracy/denial metrics.
  

• Findings & Recommendations Deck (weeks 4–8): prioritized issues with quantified impact, policy references, and rule definitions.
  

• Configuration & UAT Support (weeks 8–16, 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.