Lead Director, Coding Audit & Compliance

Job not on LinkedIn

🔥 0 minutes ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $100k - $231.5k / year

⏰ Full Time

🟠 Senior

🚔 Compliance

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• 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

🎯 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 • 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

🏖️ 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