MPPS Behavioral Health Policy Consultant

CVS Health•Hartford, TX

3d•$67,900 - $182,549•Remote

About The Position

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 Medical Policy Lead is responsible for the identification, development, and execution of behavioral health clinical and payment policies, ensuring alignment with evidence-based guidelines, regulatory requirements, and enterprise affordability goals. This role serves as a subject matter expert (SME) bridging clinical policy, coding, and claims adjudication by translating behavioral health policy intent into clear business requirements that drive accurate configuration and enforcement within claims processing platforms. The position partners across Medical Policy, Medical Coding, Compliance, and vendor teams to ensure policy is operationalized consistently across end-to-end claims workflows (intake, edits, adjudication, denials, and appeals).

Requirements

7+ years of experience in medical policy, payment policy, or correct coding; behavioral health clinical practice; or utilization management
Ability to interpret behavioral health clinical standards and translate into policy
Apply correct coding frameworks (ICD-10, CPT/HCPCS) in policy and claims contexts
Develop business requirements documents (BRDs) supporting claims system configuration
Strong knowledge of behavioral health services (e.g., psychiatry, SUD, therapy modalities) and medical necessity criteria and utilization management
Experience translating policy into medical coding logic (ICD-10, CPT, HCPCS), claims editing and adjudication rules
Demonstrated experience developing business requirements (BRDs) for system implementation
Experience with claims adjudication platforms and/or vendor editing solutions

Nice To Haves

Experience with Medicaid and/or Medicare behavioral health policy
Experience with payment integrity vendors (e.g., Cotiviti, Optum, ClaimsXten)
Strong background in policy governance, audit/remediation and process improvement / Lean methodologies
Formal training or coursework in healthcare policy or health economics, clinical informatics or data analytics and/or utilization management or population health
Ability to effectively influence cross-functional teams without formal authority

Responsibilities

Lead identification of new and emerging behavioral health policy opportunities, including: Utilization management gaps, Medical correct coding vulnerabilities, Payment integrity risks
Interpret clinical evidence, regulatory guidance, and industry best practices to: Develop or revise behavioral health medical policies, Define coverage criteria, limitations, and exclusions, Ensure policies are clinically sound, evidence-based, and aligned with CMS/state guidance
Define and drive payment policy strategies to ensure accurate claim adjudication and cost containment
Translate behavioral health policy intent into: Claims editing logic, Correct coding requirements (DX, CPT/HCPCS, modifiers, frequency rules), Adjudication outcomes (deny, pend, allow, PA requirement)
Partner with payment integrity and vendor teams (e.g., editing engines) to implement scalable solutions
Own development of detailed Business Requirements Documents (BRDs) to support policy implementation, including: Policy intent and business objectives, Coding and clinical logic, Claims system behavior across adjudication points, Configuration and testing requirements
Ensure requirements are: Clear, actionable, and testable, Aligned with claims platform capabilities (e.g., ACAS, QNXT, HRP)
Act as the primary liaison between clinical SMEs and technical/configuration teams
Partner with claims operations to ensure policy is correctly implemented across: Front-end edits, Pre-payment edits, Post-adjudication processes
Validate that behavioral health policies are correctly translated into system logic and medical coding rules
Support testing, defect resolution, and go-live readiness
Perform policy QA and validation to ensure: Alignment between clinical intent and system execution, Compliance with federal/state regulations and payer requirements
Support audits and remediation efforts by: Identifying gaps in policy, medical coding, or configuration, Driving corrective actions
Serve as Behavioral Health SME across: Medical Policy governance forums, Payment policy and vendor edit workgroups
Partner with: Clinical teams (BH providers, UM), Medical coding SMEs, Compliance and legal, IT and vendor partners
Lead end-to-end policy lifecycle from intake through execution and monitoring