Behavioral Health Compliance Specialist / Data Validation Auditor
The Behavioral Health Compliance Specialist / Data Validation Coordinator is responsible for conducting HCIC's data validation activities to ensure appropriateness of billings, claims, and encounters for covered behavioral health services in HCIC's network in accordance with state and federal guidelines. Responsibilities include preparing for, coordinating, and scheduling data validation reviewing provider claims and billing that may require adjustment or improvement; and developing and reporting findings and recommendations for further action (adjustments, recoupments, payments, resubmissions); leading coding initiative teams and tracking changes related to coding initiatives; and providing training to providers and HCIC regarding data validation and the covered services guide; conducts special investigations and analyzes patterns and trends.
1. Reviews providers claims in comparison to individual service plans, progress notes and clinical records to ensure contract requirements are met. Based on initial review, determines which providers will be audited and the data required.
2. Prepares for each audit by compiling and formatting data into useable spreadsheets, creating working papers for each audit, reviewing prior audit findings for each provider.
3. Schedules and performs audits on-site and remotely; compares claims information to member Behavioral Health Service Plan (BHSP) and progress notes, ensures that BHSP and Assessments comply with OBHL, DBHS, and AHCCCS requirements.
4. Analyzes and trends audit data and information, determines initial findings and informs provider; reviews providers responses; finalizes audits; informs HCIC Claims Unit of billing resubmissions, recoupments, adjustments and other issues requiring action and follow-up.
5. Creates data reports in the most appropriate form to report data validation activities findings to the state and various agencies.
6. Conducts special investigations, reviews and analyzes coding compliance patterns, outliers and trends.
7. Develops curricula and provides training and technical assistance to service providers relating to data validation and covered services.
8. Chairs HCIC’s Coding Information Team and participates on HCIC committees and projects as assigned.
9. Performs other duties of a similar nature and level as assigned.
A Bachelor's degree in behavioral health or related field; Master's degree preferred
Four (4) years monitoring or providing health care or human services experience; or an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position
Demonstrated knowledge of report writing based on audit findings
High level of statistics knowledge including the ability to identify trends
Knowlege of HIPPA standards
Certified Professional Coder preferred
Demonstrated problem solving skills and detail oriented
Exceptional communication skills, both written and verbal
Ability to organize and prioritize work to meet contractual deadlines
Knowledge of the Arizona behavioral health system helpful
Travel in cenntral and northern Arizona
Valid Arizona driver's license