Senior Certified Professional Behavioral Health Coder, Special Investigations Unit

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

📋 Description

• Perform thorough audits of medical records to verify that CPT/HCPCS codes and modifiers align with the documentation.

• Manage intricate coding evaluations, encompassing legal, compliance, and rework initiatives.

• Produce comprehensive written summaries detailing findings from medical record reviews.

• Communicate findings effectively to investigators, Medicaid plan leadership, law enforcement, legal counsel, providers, and state regulators.

• Analyze and discuss cases with Medical Directors to confirm decisions.

• Investigate and accurately implement state or CMS guidelines pertaining to audits.

• Support investigative research regarding coding inquiries and state and federal policies.

• Detect potential billing inaccuracies, abuse, and fraudulent activities.

• Recognize savings opportunities for cases that may require prepayment review.

• Maintain organized records, files, and documentation.

• Adhere to departmental workflows and independently meet daily work metrics.

• Guide new coders through mentorship and provide training, coding, and record review assistance.

• Collaborate with investigators, data analytics, and plan leadership on Special Investigative Unit (SIU) schemes.

• Serve as management backup during the manager's absence.

• Keep current with coding knowledge, including compliance and reimbursement updates.

⛳️ Requirements

• AAPC Coding certification — Certified Professional Coder (CPC).

• Over 3 years of experience in Behavioral Health medical coding or documentation auditing.

• Extensive knowledge of CPT, HCPCS, and ICD-10 coding manuals and guidelines.

• Familiarity with CMS 1500 and UB04 data elements.

• Experience in researching coding and policies.

• Proficient in Microsoft products, including Excel and Word.

• Previous experience auditing the work of others and providing constructive feedback.

• Experience in mentoring individuals.

• Willingness to travel to provide testimony if necessary.

• GED or High School diploma required.

• Preferred: Licensed Clinical Social Worker (LCSW), Licensed Independent Social Worker (LISW), Licensed Master Social Worker (LMSW), or Licensed Professional Counselor (LPC).

• Preferred: Strong communication skills.

• Preferred: Excellent analytical abilities.

• Preferred: Keen attention to detail and capability to review and interpret data.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources to support physical, emotional, and financial well-being.

• CVS Health bonus, commission, or short-term incentive program alongside base pay.