Quality Coding Program Manager

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

📋 Description

• Create and uphold a Quality Coding work-plan, organizing committees and workgroups to lead and supervise risk adjustment efforts.

• Execute and manage quality coding initiatives and projects.

• Collaborate with internal teams and external vendors to assess program and vendor performance, facilitating improvement activities.

• Guarantee the complete, accurate, timely, and compliant reporting of risk adjustment data in line with CMS requirements.

• Coordinate, develop, and evaluate key indicators, performance data, and reporting tools for risk adjustment operations and quality coding initiatives.

• Define, design, implement, and maintain data files and extracts for reporting purposes.

• Stay informed about relevant laws, regulations, and CMS guidance concerning risk adjustment, Medicare Advantage, and ACA/Exchange requirements.

• Provide education to providers and staff to enhance clinical documentation and improve performance and outcomes.

• Review and audit medical record documentation to confirm diagnoses and ensure compliance with CMS Risk Adjustment standards.

• Assist in CMS RADV audit readiness, which includes chart validation, mock audits, record retrieval, documentation reconciliation, and regulatory submissions.

• Identify patterns, compliance risks, and audit findings through the analysis of coding, documentation, provider, and vendor performance data.

• Collaborate with Finance to project risk adjustments and monitor the impact of coding quality.

• Potential travel may be required for auditing purposes.

• Carry out additional responsibilities as assigned.

⛳️ Requirements

• Residency in California is required; this position is exclusively open to California residents.

• Bachelor’s degree in Health Information Management, Healthcare Administration, Public Health, or a related discipline.

• Certification as a Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), or Certified Coding Specialist (CCS).

• 3–5 years of experience in medical coding, risk adjustment, HCC coding, coding audits, and provider education.

• In-depth knowledge of CMS-HCC, HHS-HCC, RADV processes, ICD-10-CM, CPT, HCPCS, risk adjustment methodologies, and CMS regulations for Medicare Advantage health plans.

• Experience in developing and managing healthcare-related programs from conception to execution in a complex, matrixed environment.

• Familiarity with a Medicare Advantage health plan or managed care setting.

• Proficiency in navigating electronic medical record (EMR/EHR) systems.

• Strong analytical, data management, problem-solving, critical-thinking, strategic-thinking, organizational, time-management, prioritization, communication, and presentation skills.

• Capability to handle multiple projects and adjust to shifting priorities and business requirements.

• Ability to convey complex information in a simplified, comprehensible manner.

• Technical ability to quickly learn new data management and analysis tools or methodologies.

• Proficient in Microsoft Office Suite.

• Valid and current Driver's License, Auto Insurance, and professional licensure(s) are required.

🏝️ Benefits

• Comprehensive health benefits.

• Retirement savings plan with employer matching.

• Professional development opportunities.

• Flexible work arrangements.