Behavioral Health Auditor

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About the role

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

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