Lead Director, Coding Audit & Compliance

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🔥 vor 23 Stunden

🤠 Texas – Remote

🤠 Texas – Remote

💵 $100.000 - $231.540 / Jahr

⏰ Vollzeit

🟠 Senior

🚔 Compliance

👻 Geisterscore 0%

Was es bedeutet: wie wahrscheinlich diese Stelle offen bleibt, ohne dass aktiv eingestellt wird.So liest du es: 60 % oder höher heißt, wir halten das für einen Geisterjob. Niedrigere Werte sind weniger bedenklich.Wie wir werten: Dauer offen, Neuveröffentlichungen, offene Stellen vs Teamgröße, wie schnell Stellen geschlossen werden, und ob ein Gehalt angegeben ist.Hinweis: eine Schätzung aus öffentlichen Daten, kein Urteil über das Unternehmen. Echte Stellen können hoch punkten, nutze es also als Hinweis, nicht als Fakt.

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CVS Health

WebsiteLinkedInAlle Stellen

10.000+ Mitarbeiter

Gegründet 1963

🏥 Gesundheitswesen

⚕️ Krankenversicherung

🛒 Einzelhandel

Healthcare • Healthcare Insurance • Retail

CVS Health ist ein führendes amerikanisches Gesundheitsunternehmen, das sich der Verbesserung des Zugangs zu Gesundheitsdiensten und deren Erschwinglichkeit verschrieben hat. Das Unternehmen verfolgt einen umfassenden Ansatz, der Gesundheitsdienstleistungen, Krankenversicherungen und das Management von Apothekenleistungen umfasst. Durch seine Tochtergesellschaften, wie Aetna und CVS Caremark, bietet CVS Health eine Vielzahl von Dienstleistungen an, die Wohlbefinden, Krankheitsmanagement und erschwinglichen Versicherungsschutz für verschreibungspflichtige Medikamente erleichtern. CVS Health betreibt Apotheken in der Nachbarschaft, bietet Versandapothekendienste an und verwaltet Programme für Spezialmedikamente, um Gesundheitsversorgung für jeden bequem und zugänglich zu machen. Angetrieben von der Mission, Menschen mit wesentlichen Pflegediensten zu verbinden, ist CVS Health bestrebt, gesündere Gemeinschaften zu fördern und das Wohlbefinden aller Menschen zu unterstützen.

Beschreibung

• Provide strategic leadership and organizational oversight for Coding Audit and Coding Compliance functions • Establish and execute coding quality, audit, and compliance strategy aligned with CMS requirements, ICD-10-CM guidelines, risk adjustment requirements, internal policies, and client contractual obligations • Establish governance, audit methodologies, quality controls, coding policies, and risk-management processes across internal and external coding operations • Serve as senior coding subject matter expert and escalation point for complex coding, audit, compliance, regulatory, and client matters • Develop and oversee a comprehensive, risk-based Coding Audit Program, including methodology, sampling strategies, quality thresholds, escalation criteria, and corrective actions • Establish coding quality and compliance standards across internal and external coding resources • Identify systemic risks and direct root-cause analysis, remediation, education, and preventive action • Establish performance measures, key risk indicators, and reporting for Coding Audit and Compliance effectiveness • Ensure coding practices align with CMS guidance, federal and state requirements, internal policies, contracts, and industry standards • Develop, interpret, implement, and maintain coding policies, guidelines, audit standards, and compliance requirements • Monitor CMS risk adjustment models, coding guidance, OIG priorities, and regulatory changes • Direct readiness activities for CMS RADV, OIG reviews, client audits, internal compliance reviews, and other regulatory or contractual audits • Advise executive leadership on material coding risks and mitigation strategies • Lead client audits, coding disputes, appeals, corrective action plans, and quality or compliance escalations • Establish governance for coding audit appeals and dispute resolution • Set coding quality and audit standards for external coding vendors • Use audit results, Business Intelligence reporting, quality data, client findings, and analytics to identify trends and improvement opportunities • Translate quality and compliance data into actionable recommendations • Provide leadership for coding application, automation, and AI/NLP-assisted coding and auditing initiatives • Establish validation, quality-control, and monitoring requirements for technology-enabled processes • Develop and execute annual and multi-year strategic roadmaps • Represent Coding Audit & Compliance in cross-functional initiatives with Coding Operations, Clinical, Product, Engineering, Analytics, Client Success, Legal, Enterprise Compliance, and Vendor Management • Provide leadership, coaching, development, succession planning, and career development for Coding Audit and Compliance staff • Oversee hiring, performance management, professional development, and personnel-management activities • Promote accountability, collaboration, continuous improvement, professional judgment, quality, and compliance

🎯 Anforderungen

• 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 • 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 • 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; ability to identify trends, assess risk, and translate complex information into actionable recommendations • 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 for 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

🏖️ Vorteile

• 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