Senior Certified Professional Behavioral Health Coder, Special Investigations Unit

Job Description:

• Conduct comprehensive medical record audits to ensure CPT/HCPCS codes and modifiers are consistent with documentation
• Handle complex coding reviews, including legal, compliance, and rework projects
• Provide detailed written summaries of medical record review findings
• Articulate findings to investigators, Medicaid plan leadership, law enforcement, legal counsel, providers, and state regulators
• Review and discuss cases with Medical Directors to validate decisions
• Research and accurately apply state or CMS guidelines related to audits
• Assist with investigative research on coding questions, state and federal policies
• Identify potential billing errors, abuse, and fraud
• Identify savings opportunities for cases that may warrant prepayment review
• Maintain records, files, and documentation
• Follow department workflows and meet daily work metrics independently
• Mentor new coders and provide training, coding, and record review guidance
• Collaborate with investigators, data analytics, and plan leadership on SIU schemes
• Act as management backup when the manager is out of the office
• Maintain up-to-date coding knowledge, including coding compliance and reimbursement changes

Requirements:

• AAPC Coding certification — Certified Professional Coder (CPC)
• 3+ years of experience in Behavioral Health medical coding or documentation auditing
• Strong knowledge of CPT, HCPCS, and ICD-10 coding guides and guidelines
• Knowledge of CMS 1500 and UB04 data elements
• Experience researching coding and policies
• Experience with Microsoft products, including Excel and Word
• Prior experience auditing others' work and providing feedback
• Experience mentoring others
• Ability to travel to provide testimony if needed
• GED or High School diploma
• Preferred: Licensed Clinical Social Worker (LCSW), Licensed Independent Social Worker (LISW), Licensed Master Social Worker (LMSW), or Licensed Professional Counselor (LPC)
• Preferred: Excellent communication skills
• Preferred: Excellent analytical skills
• Preferred: Strong attention to detail and ability to review and interpret data

Benefits:

• Medical coverage
• Dental coverage
• Vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources supporting physical, emotional, and financial well-being
• CVS Health bonus, commission or short-term incentive program in addition to base pay