Manager, Coding Quality – RADV Audits

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🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $108k - $120k / year

⏰ Full Time

🟠 Senior

🔴 Lead

👔 Manager

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HealthEdge

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2005

🏥 Healthcare

💼 Consulting

⚕️ Healthcare Insurance

Healthcare • Consulting • Healthcare Insurance

HealthEdge is a company that specializes in providing advanced solutions for healthcare payers through its HealthRules Solutions Suite. This suite includes a comprehensive digital claims administration processing system, care management workflow solutions, and payment integrity solutions, which aim to enhance operational efficiency and improve quality of care for health plans. By leveraging integrated technology and automation, HealthEdge helps health plans eliminate data silos, increase payment accuracy, and elevate member experience, thereby transforming the healthcare landscape for better collaboration and accessibility.

📋 Description

• 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

🎯 Requirements

• 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

🏖️ Benefits

• 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