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Coding Validation Specialist (Behavioral Health / Substance Use Disorder)
Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We’re constantly reimagining what’s possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.
The Coding Validation Specialist (CVS), Behavioral Health / Substance Use Disorder reviews provider medical records to validate the accuracy of outpatient facility and professional behavioral health and substance use disorder (SUD) claims. This role requires specialized knowledge of psychiatric, psychotherapy, and SUD treatment coding, including DSM-5-based diagnosis coding, H-codes, and applicable CPT and HCPCS Level II codes, to ensure the accuracy of coding, billing, and documentation. The CVS reports findings, communicates results, ensures compliance with regulatory, payer, and client requirements, and maintains quality and productivity standards. This role may be filled by a licensed nurse (RN or LPN/LVN) with coding experience, or by a certified medical coder with behavioral health/SUD specialization.
- Performs comprehensive analysis and review of claim information and associated medical records to validate that billed procedure and service codes are accurate and support the payment for behavioral health and/or SUD services.
- Maintains expert knowledge of CPT and HCPCS Level II coding conventions and rules specific to behavioral health and SUD services, including psychiatric evaluation and management, psychotherapy, medication-assisted treatment (MAT), opioid treatment program (OTP) services, intensive outpatient (IOP) and partial hospitalization (PHP) levels of care, and applied behavior analysis (ABA), as well as Official Coding Guidelines, AMA Coding Clinic, and DSM-5/ICD-10-CM diagnosis coding, remaining current on changes to coding guidelines, industry trends, and best practices.
- Analyzes, reviews, and resolves coding issues related to reimbursement, compliance, and client-specific policies for behavioral health and SUD claims.
- Validates patient data by comparing claims data received with patient medical records, including treatment plans, progress notes, and level-of-care documentation specific to behavioral health and SUD services.
- Develops and applies the appropriate rationale for any coding change affecting the APC or EAPG assignment, citing supporting references such as Official Coding Guidelines, AMA Coding guidelines, Medicare or Medicaid Billing Manuals, ASAM criteria where applicable, and coding conventions.
- Analyzes claim and supporting documentation for all claim characteristics impacting reimbursement, including revenue code and CPT/HCPCS code pairing (for example, psychiatric and chemical dependency intensive outpatient revenue codes paired with corresponding procedure codes).
- Maintains accuracy, quality, and production standards relating to the identification of incorrect coding, assignment of correct codes, and documentation of review outcomes.
- Applies working knowledge of 42 CFR Part 2 confidentiality requirements and mental health parity (MHPAEA) considerations when handling and documenting behavioral health and SUD record review.
- Uses computer applications, Grouper/Pricer software, ICD-10-CM encoder software, and Microsoft Office products.
- Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association.
- High School Diploma or equivalent GED.
- One of the following: (a) active, unrestricted nursing license (RN or LPN/LVN) in good standing, or (b) national coding certification as Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Professional Coder (CPC), or Certified Coding Specialist (CCS).
- Minimum of three years of experience in coding or auditing behavioral health and/or SUD claims.
- Working knowledge of DSM-5 diagnostic coding as applied to ICD-10-CM, and of behavioral health/SUD documentation requirements including treatment plans, progress notes, and authorization standards.
- Comprehensive knowledge of the APC structure and regulatory requirements applicable to behavioral health and SUD services.
- Comfort with AI-powered search tools and a growth mindset toward learning new technologies
- Excellent oral and written communication skills.
- Strong analytic and critical thinking skills.
- Able to work independently as well as part of a team in a production environment.
Preferred Qualifications:
- Associate or bachelor's degree in health information management, nursing, medical coding, or a related field.
- Certified Behavioral Health Coding Specialist (CBHCS) or equivalent behavioral health coding credential.
- At least two years performing post-adjudication/pre-pay or post-payment outpatient facility and/or professional claim validation specific to behavioral health or SUD claims.
- Experience coding or reviewing EAPG claims.
- Experience with medication-assisted treatment (MAT), opioid treatment programs (OTP), IOP/PHP level-of-care documentation, or ABA therapy coding and audit.
- Familiarity with mental health parity (MHPAEA) requirements and behavioral health carve-out/managed behavioral health organization (MBHO) billing structures.
- Prior clinical experience in a behavioral health or substance use disorder treatment setting (for nurse candidates).
- Work from anywhere in the US! Machinify is digital-first.
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Top Medical/Dental/Vision offerings
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FSA/HSA
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Tuition reimbursement
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Competitive salary, 401(k) with company match
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Additional health and wellness benefits and perks
- Flexible and trusting environment where you’ll feel empowered to do your best work
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