Job Summary
Position Title: Director of CodingCompliance
Position Summary: The Director of Coding Compliance is responsible for leading coding compliance and audit activities related to health plan operations, risk adjustment, payer audits and regulatory requirements. This role ensures accurate medical coding, documentation integrity, and adherence to federal, state, and payer-specific guidelines. The ideal candidate will possess advanced CPC coding expertise, strong analytical skills, and extensive experience supporting compliance initiatives within a managed care or health plan environment.
Responsibilities
Key Responsibilities
- Conduct complex coding audits and documentation reviews for accuracy, completeness, and regulatory compliance.
- Review ICD-10-CM, CPT, HCPCS, and risk adjustment coding to ensure alignment with CMS and payer guidelines.
- Identify coding trends, compliance risks, and opportunities for operational improvement.
- Partner with Compliance, SIU, Clinical Operations, Provider Education, and RCM teams to support organizational initiatives.
- Develop and deliver provider and staff education related to coding accuracy and compliance standards.
- Monitor regulatory changes and communicate impacts to leadership and operational teams.
- Assist with internal and external audit preparation, corrective action plans, and regulatory responses.
- Support oversight activities related to FWA (Fraud, Waste, and Abuse) prevention and documentation integrity.
- Analyze audit findings and prepare detailed reports, dashboards, and executive summaries.
- Serve as a subject matter expert for coding compliance and regulatory requirements.
Qualifications
Required Qualifications
- Certified Professional Coder (CPC) certification required.
- Minimum 7–10 years of medical coding and compliance auditing experience.
- Minimum 5 years of experience within a health plan, managed care organization, or payer environment.
- Strong knowledge of CMS regulations, Medicare Advantage, NYS Medicaid, HEDIS, and risk adjustment methodologies.
- Extensive experience with ICD-10-CM, CPT, and HCPCS coding systems.
- Knowledge of healthcare compliance standards and regulatory requirements.
- Experience conducting coding audits and developing corrective action plans.
- Strong analytical, communication, and leadership skills.
- Proficiency with coding and audit software applications and Microsoft Office Suite.
Preferred Qualifications
- CRC, CPMA, CCS, or other advanced coding/audit certification preferred.
- Experience supporting delegated vendor oversight and regulatory audits.
- Knowledge of NCQA standards and healthcare quality programs.
- Bachelor’s degree in Health Information Management, Healthcare Administration, Nursing, or related field preferred.
Core Competencies
- Regulatory Compliance
- Risk Assessment
- Medical Coding Expertise
- Audit & Monitoring
- Provider Education
- Cross-Functional Collaboration
- Strategic Problem Solving
- Data Analysis & Reporting
Work Environment
- Onsite - Bronx, New York Office Monday - Friday
