Director, Clinical Coding Quality
This position is remote
We are more than just a healthcare company; we are a community of professionals driven by the knowledge that our success leads to a positive impact on the communities that we support.
At ComplexCare Solutions, you’ll play a crucial part in innovating solutions that empower health plan members and healthcare providers alike. Our collaborative environment fosters creativity and initiative, ensuring that every idea and effort contributes to meaningful change in the industry. Join us and become a part of a team that turns vision into action, making a tangible impact on the future of healthcare.
Duties and Responsibilities:
- Manage day-to-day operations of the Clinical Coding Quality function, including oversight of coding quality initiatives, audit activities, and vendor performance.
- Coordinate processes involved in coding quality audits, documentation integrity reviews, risk adjustment quality programs, and compliance monitoring activities.
- Monitor HCC coding accuracy, documentation quality, and audit readiness metrics, identifying opportunities for improvement and corrective action.
- Develop and maintain coding guidance, documentation standards, audit tools, and quality assurance processes to support compliant risk adjustment practices.
- Provide oversight and performance management of external coding vendors, including quality monitoring, performance reporting, issue resolution, and remediation activities.
- Support organizational readiness for CMS, RADV, and OIG audits through audit preparation, documentation reviews, education, and ongoing quality oversight.
- Review audit findings, identify trends, and develop corrective action plans to improve coding accuracy and documentation integrity.
- Partner with health plan clients, compliance teams, and internal stakeholders to ensure alignment on coding requirements, documentation standards, risk adjustment methodologies, audit readiness activities, and regulatory expectations. Support client-facing discussions related to coding quality, documentation integrity, audit findings, and compliance initiatives.
- Collaborate with clinical leadership, operational teams, compliance, and technology partners to improve documentation quality and coding accuracy across the organization.
- Participate in the development and enhancement of clinical documentation tools and workflows to support accurate condition capture, coding compliance, and audit defensibility.
- Support provider education and training initiatives related to coding accuracy, HCC capture, documentation requirements, and regulatory compliance.
- Monitor changes in CMS guidance, ICD-10-CM coding standards, risk adjustment methodologies, and industry regulations to ensure organizational compliance and adoption of best practices.
- Develop and monitor metrics related to coding quality, documentation accuracy, audit outcomes, and vendor performance.
- Maintain compliance with CCS policies, procedures, confidentiality standards, HIPAA requirements, and all applicable regulatory requirements.
- Fulfill those responsibilities and duties reasonably assigned to support the operational and financial success of the organization.
- Responsible for the quality, training, learning and development, and quality monitoring programs related to these initiatives across ComplexCare Solutions services.
- Maintain compliance with CCS' policies, procedures and mission statement;
- Adhere to all confidentiality and HIPAA requirements as outlined within CCS’ Operating Policies and Procedures in all ways and at all times with respect to any aspect of the data handled or services rendered in the undertaking of the position.
- Fulfill those responsibilities and/or duties that may be reasonably provided by CCS for the purpose of achieving operational and financial success of the Employer.
Job Requirements:
- Minimum five (5) years’ management experience, preferably in healthcare in a senior management level role;
- Minimum two (2) years’ nursing experience;
- Strong knowledge of CMS Risk Adjustment, HCC Coding Methodology, ICD-10-CM Coding, Clinical Documentation Integrity (CDI), RADV requirements, and OIG compliance standards.
- Experience managing coding audits, quality assurance programs, and documentation integrity initiatives.
- Experience working with and overseeing external coding vendors.
- Experience developing coding policies, audit methodologies, educational materials, and quality improvement programs.
- Outstanding attention to detail with the ability to set priorities and multi-task;
- Strong computer skills required, specifically with Microsoft Office and data collections tools;
- Ability to manage and meet deadlines;
- Strong interpersonal skills; and
- Professionally skilled in verbal and written communication.
- Travel for this position will include less than 5% locally usually for training purposes.
Education:
- Bachelor's degree or equivalent required; Master's degree preferred.
- Active coding certification required, including CRC, CPC, CCS, or an equivalent credential.
- Active Registered Nurse (RN) license preferred.
The Company is proud to be an equal opportunity workplace and is an affirmative action employer. We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity, veteran status, or any other protected characteristic under federal, state, or other applicable laws.
This company utilizes E-Verify
Requires 5+ years of management experience, 2+ years of nursing experience, healthcare coding and audit expertise, strong computer and communication skills, and a bachelor's degree or equivalent.
Key Responsibilities
- managing operations
- monitoring metrics
- developing policies
Skills & Tools
Microsoft Office, ICD-10-CM
Job Details
- Category: Quality Assurance
- Seniority: Senior Level
- Commitment: Full Time
- Workplace: Remote — United States
- Salary: USD 132,000 – 174,000 / year
- Languages: English
About ComplexCare Solutions
A healthcare services organization that develops solutions for health plan members and healthcare providers. — Industry: Healthcare