Manager, Coding Quality – RADV Audits

🕒 Setembro 3

🇺🇸 Estados Unidos – Remoto (EUA)

💵 $108.000 - $120.000 / ano

⏰ Tempo Integral

🟠 Sênior

🔴 Especialista

👔 Gerente

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HealthEdge

SiteLinkedInTodas as Vagas

1001 - 5000 funcionários

Fundada em 2005

🏥 Saúde

💼 Consultoria

⚕️ Seguro de Saúde

Healthcare • Consulting • Healthcare Insurance

HealthEdge é uma empresa especializada em oferecer soluções avançadas para operadoras de saúde por meio do seu HealthRules Solutions Suite. Esse conjunto inclui um sistema digital abrangente de administração e processamento de sinistros, soluções de fluxos de trabalho (workflows) para gestão do cuidado e soluções de integridade de pagamentos, com o objetivo de ampliar a eficiência operacional e melhorar a qualidade do cuidado para os planos de saúde. Ao alavancar tecnologia integrada e automação, a HealthEdge ajuda os planos a eliminar silos de dados, aumentar a precisão dos pagamentos e elevar a experiência dos beneficiários, transformando o ecossistema de saúde para maior colaboração e acessibilidade.

Descrição

• Provide strategic leadership, planning, project coordination, and operational oversight for CMS-mandated RADV audits across Medicare Advantage and Commercial lines of business • Develop and implement audit strategies, workflows, processes, and performance objectives • Establish priorities and balance departmental workloads to maximize productivity, quality, efficiency, and resource utilization • Direct departmental operations, including planning, problem-solving, staff development, performance management, and organizational communication • Translate business and regulatory requirements into actionable objectives and measurable outcomes • Identify process-improvement and operational-efficiency opportunities and implement sustainable solutions • Provide executive-level and cross-functional leadership for strategic initiatives and regulatory activities • Lead special projects, initiatives, and complex problem-resolution efforts • Monitor departmental performance, identify trends and risks, and implement corrective actions • Foster partnerships across business, clinical, compliance, technology, and operational teams • Ensure departmental activities align with CMS regulations, company policies, contractual requirements, and industry standards • Supervise exempt and non-exempt employees • Interview, select, hire, onboard, and train employees • Plan, assign, prioritize, and direct work • Establish performance expectations and conduct performance evaluations • Coach, develop, recognize, and counsel employees • Support improved quality coding reporting • Address employee concerns and resolve workplace issues • Manage staffing levels, resource allocation, and departmental capacity • Develop and interpret policies and procedures and recommend changes to senior management

🎯 Requisitos

• Bachelor’s degree preferred; candidates with a clinical license and extensive relevant experience may be considered in lieu of degree • Required coding certification: CPC, COC, or CRC from AAPC, or CCS or CCS-P from AHIMA • Minimum of 7 years of experience in risk adjustment programs • Minimum of 3 years of management experience in a medical coding quality assurance environment with demonstrated technical experience • Experience within the healthcare payer industry, including health plans, third-party administrators, benefits consulting, or healthcare technology organizations • Experience leading complex, enterprise-level projects, programs, or regulatory initiatives • Knowledge and practical experience with CMS regulations and requirements • Proficiency with Microsoft Word, Excel, and PowerPoint required • Experience with Microsoft Project preferred • Experience with JIRA or similar project-management tools preferred • Ability to work across multiple time zones in a hybrid or remote work environment • May be required to pass a pre-employment criminal background check • Must meet physical demands including extended periods sitting and/or standing at a computer

🏖️ Benefícios

• Commitment to continuous professional development and learning • Professional development and continuous learning support • Reasonable accommodations for individuals with disabilities • Potential travel dependent on company needs