[Hiring] Lead Director, Coding Audit & Compliance @CVS Health

Role Description

In this role you will provide strategic leadership and organizational oversight for the Coding Audit and Coding Compliance functions. You will be accountable for establishing and executing the coding quality, audit, and compliance strategy to ensure accurate, complete, and consistent coding in accordance with CMS requirements, ICD-10-CM guidelines, risk adjustment requirements, internal policies, and client contractual obligations.

You will also establish governance, audit methodologies, quality controls, coding policies, and risk-management processes across internal and external coding operations. You will serve as a senior coding subject matter expert and escalation point for complex coding, audit, compliance, regulatory, and client matters and advise leadership on material risks, trends, and mitigation strategies.

Qualifications

• 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.
• Demonstrated 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.
• Demonstrated 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 with demonstrated ability to identify trends, assess risk, and translate complex information into actionable recommendations.
• Demonstrated 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 with the ability to effectively communicate with operational, clinical, technical, client-facing, and executive audiences.

Requirements

• Certified Professional Medical Auditor (CPMA) preferred.
• Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) preferred.
• Healthcare compliance certification such as 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 preferred.

Benefits

• Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.
• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources, based on eligibility.

Pay Range

The typical pay range for this role is: $100,000.00 - $231,540.00. This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. This position also includes an award target in the company’s equity award program.