The role leads the organization's comprehensive medical coding operations overseeing both professional and hospital coding service lines and provides strategic and operational leadership for utilization management, clinical documentation excellence, and physician advisory services. The role ensures optimal resource utilization, accurate clinical documentation, regulatory compliance, and maximum appropriate reimbursement while supporting the institution's clinical, research, and educational missions.

Essential Duties and Responsibilities:

Operational Leadership Coder Education Provider Education Analytics Support Technology/Workflow Optimization

Direct and oversee day-to-day operations of the clinical revenue cycle.

Ensure timely, accurate, and compliant coding, charge capture and patient status across hospitals and medical groups.

Establish operational priorities, performance standards, and service expectations for all assigned functional areas.

Monitor workload distribution, staffing effectiveness, productivity, and operational throughput to ensure optimal performance.

Lead process improvement efforts to standardize workflows, reduce manual rework, and increase efficiency.

Financial Accountability

Identify and address sources of revenue leakage, reimbursement delays, and process failures affecting account resolution and/or net revenue collections.

Oversee escalation and resolution of high-value, high-complexity, or high-risk accounts.

Lead the denial management strategy to significantly reduce clinical and coding payer denials.

Establish accountability mechanisms for denial reduction and appeal recovery performance.

Ensure consistent tracking, categorization, and reporting of clinical and coding denials by payer, service line, department, entity, and root cause. Collaborate with upstream and downstream stakeholders to resolve issues affecting financial performance related to utilization management, coding, and documentation.

Forecast financial impacts of changing CMS regulations, IPPS updates, and commercial payer policies.

Implement processes to ensure DRG optimization, E&M documentation, HCC capture rates, and UM decision making.

Implement processes to improve CMI and RAF performance.

Compliance and Quality Management

Develop and enforce policies for admission, continued stay, and discharge reviews.

Lead interdisciplinary initiatives to optimize level of care decisions, length of stay, and medical necessity documentation.

Integrate clinical documentation practices with quality metrics and risk adjustment.

Ensure strict adherence to CMS, OIG, HIPPA and official coding guidelines.

Oversee internal and external coding audit programs.

Mitigate compliance risks by implementing corrective action plans.

Serve as the primary liaison for coding compliance investigations.

Support value-based contract performance.

Align documentation with population health outcomes.

Physician Engagement, Education, and Collaboration

Deploy Physician Advisors to manage complex medical necessity reviews.

Educate providers on documentation specificity and compliance.

Present performance data to clinical chairs to drive engagement.

Educate physicians on the direct link between clinical documentation, risk adjustment and health system funding.

Engage clinical department chairs and faculty with data transparency to improve documentation specificity.

Drive peer-to-peer appeal processes to secure appropriate financial reimbursement.

Assist in development of EHR workflows to assist in teaching physicians.

Analytics, Reporting, and Performance Management

Develop, analyze, and present operational and financial performance reports, dashboards, and trend analyses for executive leadership and operational stakeholders.

Monitor key performance indicators and identify opportunities for improvement at the enterprise, entity, specialty, department, payer, and functional levels.

Use data to inform resource allocation, operational redesign, vendor oversight, and strategic initiatives.

Translate analytics into actionable plans with measurable outcomes and accountability.

Technology and Process Optimization

Implement technology solutions including AI-driven CDI and electronic UM workflows

Partner with information technology and operational leaders to optimize Epic functionality, work queues, automation tools, edits, and workflow design.

Lead or support system implementation, conversion, upgrade, and optimization efforts related to areas of responsibility within the clinical revenue cycle

Recommend and implement technology-enabled solutions that improve productivity, reduce denials, enhance reporting, and strengthen provider engagement.

Optimize coding workflows to minimize discharged not final billed (DNFB) and Professional Pre-AR.

Leadership and Talent Management

Provide leadership, coaching, and performance management to managers, supervisors, and staff within patient financial services.

Foster a culture of accountability, continuous improvement, collaboration, service excellence, and equity.

Develop staff capabilities through mentoring, education, and succession planning. Chief Clinical Revenue Cycle

Ensure clear communication of goals, organizational priorities, policy updates, and performance expectations.

Vendor Management

Oversee performance of external vendors, agencies, and business partners supporting coding functions or other specialized services.

Establish service level expectations, review performance trends, and ensure contractual compliance and value realization.

Escalate and resolve vendor-related issues affecting revenue leakage or compliant coding and billing.

Knowledge, Skills, and Abilities

Expert knowledge of CMS guidelines and Medicare Conditions of Participation, DRG assurance, and Hierarchical Condition Categories (HCC).

Expertise in InterQual or MCG criteria and clinical architecture.

Strong negotiation skills for payer disputes and physician engagement. Ability to analyze complex financial and operational data, identify trends, and drive measurable improvement.

Strong leadership, organizational, and change management skills.

Excellent written and verbal communication skills, including the ability to present to senior executives, physicians, faculty practice leaders, and cross-functional stakeholders.

Ability to build collaborative relationships across operational, clinical, administrative, and academic teams.

Strong problem-solving, decision-making, and execution skills in a dynamic and highly regulated environment.

Commitment to patient-centered service, operational integrity, compliance, and continuous improvement.

MINIMUM REQUIREMENTS

Education: MD, DO, or APP degree from an accredited medical school Experience: Cumulative 10 years of leadership experience in medical decision making, utilization management, case management, clinical documentation improvement or coding compliance with a demonstrated track record of success

Licensure: Active state medical license and current board certification. Preferred Certifications: CHCQM or standard physician advisor. Certified Case Manager (CCM), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), Certified Professional in Utilization Review (CPUR), Certified Professional Coder CPC), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician-based (CCS-P), or Certified Inpatient Coder (CIC).

MINIMUM REQUIREMENTS:

Education: Bachelor's degree required.

Experience: 10 years relevant experience.

Licensure: None.

PHYSICAL DEMANDS:

This is primarily a sedentary job involving extensive use of desktop computers. The job does occasionally require traveling some distance to attend meetings, and programs.

Job Profile
J1138 - Business and Finance Senior Administrator 1

Career Stream and Level
Senior Administrator-S1