Behavioral Health Coding Auditor

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 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.
HS Diploma or equivalent work experience.
5+ Years
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 Skill Profession

Healthcare Support