Lead Director, Coding Audit & Compliance

CVS Health•Work At Home-Texas, TX

1d•$100,000 - $231,540

About The Position

In this role you will provide strategic leadership and organizational oversight for the Coding Audit and Coding Compliance functions. You will be accountable for establishing and executing the coding quality, audit, and compliance strategy to ensure accurate, complete, and consistent coding in accordance with CMS requirements, ICD-10-CM guidelines, risk adjustment requirements, internal policies, and client contractual obligations. You will also establish governance, audit methodologies, quality controls, coding policies, and risk-management processes across internal and external coding operations. You will serve as a senior coding subject matter expert and escalation point for complex coding, audit, compliance, regulatory, and client matters and advise leadership on material risks, trends, and mitigation strategies.

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 audit, coding compliance, healthcare quality, or risk adjustment.
Five or more years of progressive leadership experience within a medical coding, audit, compliance, quality, or risk adjustment environment.
Experience leading managers, supervisors, team leads, or multiple functional teams strongly preferred.
Demonstrated experience developing or overseeing coding audit, quality assurance, compliance, or risk-management programs.
Significant experience with Medicare risk adjustment, CMS requirements, coding audits, and complex quality or compliance matters.
Active Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent nationally recognized coding credential.
Certified Risk Adjustment Coder (CRC) required.
Advanced knowledge of ICD-10-CM coding guidelines, CMS risk adjustment requirements, HCC models, medical record documentation requirements, and coding compliance principles.
Advanced knowledge of coding audit methodologies, quality assurance, risk assessment, root-cause analysis, and corrective action processes.
Demonstrated ability to interpret complex coding and regulatory requirements and translate them into policies, controls, operational requirements, and organizational recommendations.
Strong analytical and decision-making skills with demonstrated ability to identify trends, assess risk, and translate complex information into actionable recommendations.
Demonstrated ability to lead within a matrixed organization, influence stakeholders outside direct reporting relationships, and manage complex cross-functional initiatives.
Excellent written and verbal communication skills with the ability to effectively communicate with operational, clinical, technical, client-facing, and executive audiences.

Nice To Haves

Certified Professional Medical Auditor (CPMA).
Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT).
Healthcare compliance certification such as Certified in Healthcare Compliance (CHC).
Experience with CMS RADV, OIG risk adjustment initiatives, client coding audits, and regulatory reviews.
Experience with Medicare, Medicaid, and ACA risk adjustment methodologies.
Experience with Business Intelligence tools, coding quality analytics, and AI/NLP-assisted coding or auditing technologies.

Responsibilities

Provides strategic leadership and direction for the Coding Audit and Coding Compliance functions, establishing priorities, performance expectations, and short- and long-term objectives.
Develops and oversees a comprehensive, risk-based Coding Audit Program, including audit methodology, sampling strategies, quality thresholds, escalation criteria, and corrective action requirements.
Establishes coding quality and compliance standards across internal and external coding resources to promote accuracy, completeness, specificity, clinical support, and adherence to applicable coding and regulatory requirements.
Identifies systemic coding quality and compliance risks and directs root-cause analysis, remediation, education, and preventive action.
Establishes performance measures, key risk indicators, and reporting to monitor Coding Audit and Compliance effectiveness and provide leadership with visibility into emerging trends and areas of risk.
Provides oversight of coding-specific compliance and ensures coding practices align with CMS guidance, Federal and State requirements, internal policies, contractual requirements, and applicable industry standards.
Leads the development, interpretation, implementation, and maintenance of coding policies, internal coding guidelines, audit standards, and compliance requirements.
Monitors changes in CMS risk adjustment models, coding guidance, OIG priorities, and regulatory requirements and evaluates their potential impact on coding operations, policies, technology, education, and controls.
Directs coding-related readiness activities for CMS Risk Adjustment Data Validation (RADV), OIG reviews, client audits, internal compliance reviews, and other regulatory or contractual audits.
Serves as a senior escalation point for complex or high-risk coding interpretations and compliance issues and partners with Clinical, Legal, Enterprise Compliance, and other stakeholders as appropriate.
Advises executive leadership regarding material coding risks and recommends appropriate corrective, preventive, or risk-mitigation actions.
Provides senior Coding leadership for significant client audits, coding disputes, appeals, corrective action plans, and quality or compliance escalations.
Establishes governance for coding audit appeals and dispute resolution, including escalation standards, adjudication expectations, trend analysis, and systemic corrective action.
Establishes coding quality and audit standards for external coding vendors, including quality thresholds, audit requirements, escalation criteria, and remediation expectations.
Partners with Coding Operations and Vendor Management to evaluate significant or recurring vendor quality concerns while maintaining appropriate separation between vendor operational management and independent quality/compliance oversight.
Leverages audit results, Business Intelligence reporting, quality data, client findings, and other analytics to identify coding trends, emerging risks, and opportunities for improvement.
Translates quality and compliance data into actionable recommendations for Coding leadership and cross-functional stakeholders.
Provides Coding Audit and Compliance leadership for technology initiatives, including coding application development, automation, and AI/NLP-assisted coding and auditing solutions.
Establishes appropriate validation, quality-control, and ongoing monitoring requirements for technology-enabled coding and audit processes.
Identifies opportunities to improve the effectiveness, scalability, and efficiency of Coding Audit and Compliance through process redesign, analytics, automation, and technology.
Advises the Executive Director and senior leadership regarding coding quality, regulatory developments, client concerns, audit findings, compliance exposure, and mitigation strategies.
Represents Coding Audit & Compliance in cross-functional initiatives involving Coding Operations, Clinical, Product, Engineering, Analytics, Client Success, Legal, Enterprise Compliance, Vendor Management, and other stakeholders.
Develops and executes the annual and multi-year strategic roadmap for Coding Audit and Compliance aligned with organizational objectives and anticipated regulatory, technology, workforce, and client needs.
Provides coding expertise and recommendations that influence organizational policies, operational processes, technology development, client commitments, quality standards, and strategic priorities.
Provides leadership, direction, coaching, and development to Coding Audit and Coding Compliance leaders and professional staff.
Establishes clear accountability, performance expectations, and departmental objectives aligned with organizational goals.
Develops leadership capability, technical expertise, succession plans, and career development opportunities within Coding Audit and Compliance.
Oversees hiring, performance management, professional development, and other personnel-management activities within assigned functions.
Promotes a culture of accountability, collaboration, continuous improvement, professional judgment, quality, and compliance.