Behavioral Health Policy Consultant

This is a fully remote position, open to applicants in Texas.

📋 Description

• Responsible for identifying, developing, and implementing behavioral health clinical and payment policies.

• Act as a subject matter expert (SME) that connects clinical policy, coding, and claims adjudication.

• Collaborate with teams across Medical Policy, Medical Coding, Compliance, and vendors to ensure the operationalization of policies.

• Define and drive strategies for payment policy to guarantee accurate claim adjudication and cost containment.

• Oversee the creation of comprehensive Business Requirements Documents (BRDs).

• Ensure that behavioral health policies are accurately reflected in system logic and medical coding rules.

• Conduct policy quality assurance and validation to maintain alignment between clinical intent and system execution.

• Serve as the Behavioral Health SME in Medical Policy governance forums.

• Manage the entire policy lifecycle from initial intake through execution and ongoing monitoring.

⛳️ Requirements

• Over 7 years of experience in medical policy, payment policy, correct coding, behavioral health clinical practice, or utilization management.

• Capability to interpret behavioral health clinical standards and translate them into policy.

• Proficiency in applying correct coding frameworks (ICD-10, CPT/HCPCS) in policy and claims contexts.

• Ability to develop business requirements documents (BRDs) that support claims system configuration.

• Strong understanding of behavioral health services (e.g., psychiatry, SUD, therapy modalities) and criteria for medical necessity and utilization management.

• Experience in translating policy into medical coding logic (ICD-10, CPT, HCPCS), as well as claims editing and adjudication rules.

• Proven experience in developing business requirements (BRDs) for system implementation.

• Familiarity with claims adjudication platforms and/or vendor editing solutions.

🏝️ Benefits

• Medical, dental, and vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources based on eligibility.