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.