Behavioral Health Auditor

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary
The Behavioral Health Auditor is responsible for reviewing medical, behavioral health, and other healthcare provider records to ensure compliance with coding, documentation, state, federal, and regulatory requirements, including standards established by the Louisiana Department of Health and Office of Behavioral Health. The Auditor must be able to determine coding accuracy and documentation appropriateness through record reviews and audits.

Responsibilities include conducting provider audits, identifying coding and documentation deficiencies, recognizing concerning billing patterns or trends, and recommending appropriate follow-up actions. Follow-up actions may include provider education, corrective action plans, and referrals for suspected fraud, waste, and abuse (FWA).

The Behavioral Health Auditor collaborates with internal and external stakeholders to support audit activities, ensure regulatory compliance, assist with FWA prevention and detection efforts, provide technical assistance and education to providers, and support continuous quality improvement initiatives. The Auditor is expected to maintain professional competency and remain informed of evolving regulatory requirements and industry best practices.

General Responsibilities

• Complete a variety of medical, behavioral health, and clinical audits.
• Serve as a member of the audit team supporting a health plan that administers benefits across multiple lines of business, including Medicaid, acute care, behavioral health, individuals with developmental disabilities, and children in out-of-home care.
• Audit provider records to ensure coding and documentation comply with regulatory, contractual, organizational, Louisiana Department of Health, and Office of Behavioral Health standards.
• Examine treatment records to ensure required and appropriate documentation is present and supports services billed.
• Audit provider records to ensure appropriate use of procedure codes, modifiers, places of service, and supporting documentation.
• Assist with the development, implementation, administration, and monitoring of corrective action plans for providers.
• Complete data entry and maintain audit records using designated audit tools and systems.
• Participate in inter-rater reliability activities and scoring guideline development to ensure audit consistency.
• Assist with the development and implementation of prospective and retrospective FWA prevention, detection, and referral initiatives.
• Support the creation, compilation, and submission of regulatory deliverables through timely completion of audit activities.
• Provide technical assistance, education, and training to providers regarding regulatory requirements, coding guidelines, documentation standards, evidence-based practices, patient involvement and consent, patient safety, cultural competence, and transitions of care.
• Develop and maintain positive working relationships with providers to promote cooperation, engagement, compliance, and provider satisfaction.
• Participate in Quality Management (QM) meetings and related activities.
• Collaborate with team members to improve audit methodologies, measurement processes, and quality monitoring activities, recommending new policies and procedures when appropriate.
• Monitor regulatory changes by reviewing existing and new legislation and communicating impacts, recommendations, and required actions to leadership.
• Maintain professional knowledge, skills, and competencies through continuing education and professional development activities.
• Maintain compliance with organizational policies, procedures, confidentiality requirements, and applicable regulatory standards.
• Maintain individual professional licensure in good standing and adhere to all requirements established by the applicable licensing board.
• Perform other duties as assigned.
  
  Required Qualifications
  
• Licensed Mental Health Provider in the State of Louisiana, in good standing and without restrictions (LPC, LMFT, LCSW, LMSW, APRN).
• Minimum of five (5) years of professional work experience, including experience in behavioral health services.
• Three (3) to five (5) years of experience reviewing and interpreting claims data, medical records, and clinical documentation.
• Knowledge of behavioral health documentation requirements, evidence-based treatment practices, and regulatory standards.
• Knowledge of medical terminology and healthcare documentation standards.
• Strong problem-solving and decision-making skills.
• Proficiency with digital systems and technology applications.
• Ability to interpret and analyze clinical, claims, and audit data.
• Ability to handle sensitive and confidential information ethically and responsibly.
• Ability to communicate effectively and interact professionally with providers, members, customers, and community partners.
• Ability to function effectively within clinical environments and work with diverse patient and staff populations.
• Ability to evaluate risks, costs, and benefits when making recommendations and decisions.
• Must reside in Louisiana.
• Willingness to travel up to 25% throughout Louisiana.
• Willingness to work Monday through Friday, 8:00 a.m. to 5:00 p.m. Central Time.
• Must possess, or be willing to obtain, a Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) certification.

• Master’s degree.

Preferred Qualifications
Previous auditing experience.

• Previous experience in an outpatient behavioral health setting.
• Previous experience working with medical records and/or electronic health records (EHRs).
• Previous Medicaid, managed care, or health plan experience.
• Previous experience with Louisiana Department of Health and/or Office of Behavioral Health regulations and provider requirements.
• Previous experience with Quickbase.
• Strong organizational and time management skills.
• Demonstrated ability to work independently and manage multiple priorities.
• Strong analytical, critical thinking, and problem-solving abilities.
• Exceptional attention to detail and accuracy.
• Ability to learn quickly and adapt to changing priorities and regulatory requirements.
• Strong relationship-building and collaboration skills.
• Excellent written, verbal, and presentation skills.
• Ability to work effectively both independently and as part of a team.
• Demonstrated flexibility and adaptability in a dynamic work environment.

Education
Master's degree

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Additional details about available benefits are provided during the application process and onBenefits Moments.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.