Manager, Medical Review Coding - Behavioral Health US

The Manager, Medical Review Coding - Behavioral Health leverages deep expertise in Behavioral Health Coding and the related payment integrity landscape to own operational results for a remote team of coders and audit roles performing behavioral health coding audits. The Manager is accountable for audit quality, team performance, segment strategy, and serves as the organization's subject matter expert across behavioral health CPT coding, DSM-5-based diagnostic coding, and applicable payer and regulatory requirements. Responsible for driving strategy activities including needs assessments, capacity planning, staffing models, cost/benefit analysis, and establishing productivity and quality standards specific to behavioral health audit operations.

Key Responsibilities:

• Provides operational oversight of the outpatient behavioral health coding audit team; serves as the primary subject matter expert for behavioral health coding including psychiatric and psychological services, substance use disorder treatment, ABA, H-codes, and HCPCS Level II behavioral health codes.
• Leads development, maintenance, and refinement of behavioral health review guidelines and audit concepts, ensuring alignment with CMS, Medicaid, and commercial payer policies; monitors and interprets regulatory and policy changes including DSM-5 updates, coverage expansions, Medicaid carve-out requirements, and parity regulations.
• Partners with clinical leadership, audit management, segment specialists, and adjacent QA and appeals teams to implement new clients and concepts, align on escalations, and drive continuous improvement in behavioral health audit workflows.
• Proactively identifies opportunities for cost savings, revenue protection, and outcome improvement; uses data and clinical expertise to identify capacity gaps, backlogs, and performance risks and align resources to meet SLAs and business objectives.
• Manages daily activities of coding audit staff; provides behavioral health-specific guidance, trend identification, coaching, and constructive feedback to drive performance and quality outcomes.
• Oversees staffing levels, time and attendance, performance reviews, and corrective action in collaboration with HR and senior management.
• Provides operational and performance reporting to senior management; participates in department and client-facing meetings and presents behavioral health coding findings, solutions, and provider education as needed.
• Leads development of training materials and best practices; ensures all audit staff are equipped with current tools, resources, and training to perform behavioral health coding audits accurately and efficiently.
• Maintains current knowledge of behavioral health industry changes including regulations, payer policy, and business trends; fosters a team environment built on open communication, continuous improvement, and high performance.
• Performs other duties as required and assigned to meet business needs.

Knowledge, Skills, and Abilities Needed:

• Expert knowledge of outpatient behavioral health coding including psychiatric E/M, psychotherapy, neuropsychological testing, substance use disorder treatment, ABA therapy, and crisis intervention CPT codes across professional and facility settings.
• In-depth knowledge of DSM-5 diagnostic coding as applied to ICD-10-CM, and medical documentation requirements for behavioral health services including treatment plans, progress notes, provider credential requirements, and authorization standards.
• Strong knowledge of CPT, HCPCS Level II, ICD-10-CM, and CMS, Medicaid, and commercial payer coverage and payment rules for behavioral health services, including mental health parity requirements.
• Proficiency with CMS-1500 claim forms, behavioral health billing workflows, encoders, and EHR systems; ability to navigate and interpret electronic behavioral health records.
• Proven ability to review, analyze, and research complex behavioral health coding, documentation, and reimbursement issues; experience with claims software and reimbursement policy analysis.
• Demonstrated ability to apply sound clinical and coding judgment to make defensible decisions on complex audit matters and identify opportunities for workflow improvement and efficiency.
• Experience developing and implementing behavioral health coding processes, procedures, and training; skilled in inventory management, resource planning, and operational reporting.
• Strong analytical skills with the ability to synthesize complex clinical and claims data, identify trends, and present data-driven solutions to leadership.
• Excellent written and verbal communication skills; ability to engage effectively with internal teams, providers, clients, and payer stakeholders at all levels.
• Demonstrated ability to lead, motivate, and hold accountable a high-performing remote team; provides coaching and constructive feedback to drive results.
• Strong proficiency with Microsoft Office (intermediate to advanced Excel); experience with reporting tools and case management systems; ability to quickly learn new systems and tools.
• Self-starter with the ability to work independently in a remote environment; flexible and able to thrive amid evolving regulatory and payer requirements.
• Must complete a Teleworker Agreement upon hire and maintain compliance with HIPAA, confidentiality standards, appropriate workspace requirements, and high-speed internet connectivity.

Required and Preferred Qualifications:

• Current certification as a CPC, CPC-P, RHIA, RHIT, or CCS, required; CPMA (Certified Professional Medical Auditor) strongly preferred.
• Certified Behavioral Health Coding Specialist (CBHCS) or equivalent behavioral health coding credential strongly preferred.
• 5+ years of outpatient behavioral health medical coding and/or coding audit experience in a provider, payer, or payment integrity setting; behavioral health specialization is required, not preferred.
• 5+ years of direct experience coding or auditing behavioral health outpatient claims, including psychiatric services, SUD treatment, ABA therapy, and/or psychological testing.
• Demonstrated knowledge of behavioral health documentation requirements and DSM-5 coding application in outpatient clinical settings.
• 4+ years of relevant management or supervisory experience in a similar business environment, preferably overseeing remote audit or coding teams.
• Prior experience in payer edit development, reimbursement policy, or behavioral health payment integrity a plus.
• Experience with behavioral health carve-out programs, state Medicaid managed behavioral health organizations (MBHOs), or federal behavioral health payment programs a plus.