Senior Certified Professional Behavioral Health Coder, Special Investigations Unit
Core
Conduct comprehensive medical record audits and reviews for the Special Investigations Unit to ensure coding compliance, identify billing errors/fraud, and support legal/regulatory investigations.
Role type
Senior Certified Professional Behavioral Health Coder (IC)
Builds
Compliance audit reports, investigative findings, and validated coding decisions for behavioral health claims.
Domain
Healthcare compliance, behavioral health, medical auditing, fraud detection.
Required skills
Behavioral health medical coding, CPT/HCPCS/ICD-10 guidelines, CMS 1500/UB04 data elements, audit research, fraud detection, mentoring, Microsoft Excel/Word.
Preferred skills
Licensed Clinical Social Worker (LCSW), Licensed Independent Social Worker (LISW), Licensed Master Social Worker (LMSW), Licensed Professional Counselor (LPC).
Technologies
CMS 1500, UB04, CPT, HCPCS, ICD-10, Microsoft Excel, Microsoft Word.
Responsibilities
Conduct comprehensive medical record audits to ensure CPT/HCPCS modifiers are consistent with documentation; Resolve complex coding issues and review claims for legal, compliance, or rework projects; Articulate findings to investigators, law enforcement, and regulators; Identify potential billing errors, abuse, and fraud; Mentor new coders and provide training; Act as management backup for the team.
Seniority
Senior, hands-on IC with mentoring responsibilities.
