Lead Director, Coding Audit & Compliance
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Job Description
Leading CVS Health’s coding audit and compliance strategy for healthcare risk adjustment operations. Overseeing governance, regulatory readiness, analytics, technology, vendors, and coding teams.
Responsibilities:
- 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
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