Lead Director, Coding Audit & Compliance

This is a fully remote position, open to applicants in Texas.

📋 Description

• Provide strategic direction and organizational oversight for Coding Audit and Coding Compliance functions.

• Develop and implement coding quality, audit, and compliance strategies that adhere to CMS requirements, ICD-10-CM guidelines, risk adjustment standards, internal policies, and client contracts.

• Create governance structures, audit methodologies, quality controls, coding policies, and risk-management processes across both internal and external coding operations.

• Act as a senior subject matter expert in coding and serve as an escalation point for intricate coding, audit, compliance, regulatory, and client issues.

• Design and manage a comprehensive, risk-based Coding Audit Program, including methodology, sampling techniques, quality thresholds, escalation criteria, and corrective measures.

• Set coding quality and compliance standards across both internal and external coding resources.

• Identify systemic risks and lead root-cause analysis, remediation, education, and preventive actions.

• Establish performance metrics, key risk indicators, and reporting mechanisms to assess the effectiveness of Coding Audit and Compliance.

• Ensure coding practices comply with CMS guidance, federal and state regulations, internal policies, contracts, and industry standards.

• Formulate, interpret, implement, and maintain coding policies, guidelines, audit standards, and compliance obligations.

• Monitor CMS risk adjustment models, coding guidance, OIG priorities, and regulatory developments.

• Direct readiness efforts for CMS RADV, OIG reviews, client audits, internal compliance evaluations, and other regulatory or contractual audits.

• Counsel executive leadership on significant coding risks and mitigation strategies.

• Manage client audits, coding disputes, appeals, corrective action plans, and quality or compliance escalations.

• Establish governance for coding audit appeals and dispute resolution processes.

• Set coding quality and audit benchmarks for external coding vendors.

• Utilize audit findings, Business Intelligence reports, quality data, client insights, and analytics to pinpoint trends and opportunities for improvement.

• Transform quality and compliance data into actionable recommendations.

• Provide leadership for initiatives related to coding applications, automation, and AI/NLP-assisted coding and auditing.

• Establish validation, quality-control, and monitoring requirements for technology-enabled processes.

• Develop and implement annual and multi-year strategic roadmaps.

• Represent Coding Audit & Compliance in cross-functional initiatives involving Coding Operations, Clinical, Product, Engineering, Analytics, Client Success, Legal, Enterprise Compliance, and Vendor Management.

• Offer leadership, coaching, development, succession planning, and career growth opportunities for Coding Audit and Compliance staff.

• Oversee hiring, performance management, professional development, and personnel management activities.

• Foster accountability, collaboration, continuous improvement, professional judgment, quality, and compliance.

⛳️ Requirements

• Bachelor's degree in Health Information Management, Healthcare Administration, Business Administration, Health Sciences, or a related field preferred; equivalent relevant education, certification, and experience may be considered.

• Eight or more years of progressive experience in medical coding, coding audits, coding compliance, healthcare quality, or risk adjustment.

• Five or more years of progressive leadership experience in a medical coding, audit, compliance, quality, or risk adjustment setting.

• Experience in leading managers, supervisors, team leads, or multiple functional teams is strongly preferred.

• Experience in developing or overseeing coding audit, quality assurance, compliance, or risk-management programs.

• Extensive experience with Medicare risk adjustment, CMS requirements, coding audits, and complex quality or compliance issues.

• Active Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent nationally recognized coding credential is required.

• Certified Risk Adjustment Coder (CRC) is mandatory.

• Advanced understanding of ICD-10-CM coding guidelines, CMS risk adjustment requirements, HCC models, medical record documentation standards, and coding compliance principles.

• Advanced knowledge of coding audit methodologies, quality assurance, risk assessment, root-cause analysis, and corrective action processes.

• Ability to interpret complex coding and regulatory requirements and translate them into policies, controls, operational needs, and organizational recommendations.

• Strong analytical and decision-making capabilities; ability to identify trends, assess risks, and convert complex information into actionable recommendations.

• Capacity to lead within a matrixed organization, influence stakeholders outside direct reporting lines, and manage complex cross-functional projects.

• Exceptional written and verbal communication skills tailored to operational, clinical, technical, client-facing, and executive audiences.

• Preferred: Certified Professional Medical Auditor (CPMA).

• Preferred: Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT).

• Preferred: Certified in Healthcare Compliance (CHC).

• Preferred experience with CMS RADV, OIG risk adjustment initiatives, client coding audits, and regulatory reviews.

• Preferred experience with Medicare, Medicaid, and ACA risk adjustment methodologies.

• Preferred experience with Business Intelligence tools, coding quality analytics, and AI/NLP-assisted coding or auditing technologies.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program.

• Award target in the company’s equity award program.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Other resources supporting physical, emotional, and financial well-being, based on eligibility.