Director, Risk Adjustment Coding - Certified

Job Description Summary

‎ 

‎ 

How will you make an impact & Requirements

‎ 

The Director will lead certified coding teams, establishes coding governance and quality programs, partners cross-functionally with Clinical, Compliance, Operations, Analytics, and Vendor Management, and drives continuous improvement across prospective, concurrent, and retrospective Risk Adjustment initiatives.

Key Responsibilities Risk Adjustment Coding Strategy & Leadership

• Provide enterprise leadership for Risk Adjustment coding strategy across all

• programs, including prospective, concurrent, and retrospective reviews.

• Establish and maintain standardized coding policies, procedures, and

• documentation practices aligned with CMS Risk Adjustment regulations.

• Translate Risk Adjustment strategy into scalable coding operations that support accurate RAF capture and audit defensibility.

• Serve as the subject matter expert for Risk Adjustment coding interpretation and best practices.

Team Leadership & Development

• Lead, mentor, and develop teams of certified Risk Adjustment coders and coding leaders.

• Establish productivity, quality, and accuracy benchmarks for internal coding teams.

• Foster a culture of accountability, compliance, and continuous learning.

• Ensure ongoing coder education related to CMS guidance, ICD-10-CM updates,

• and regulatory changes.

Quality, Audit & Compliance Oversight

• Design and oversee Risk Adjustment coding quality assurance and audit

• programs.

• Partner with Compliance and Audit teams to ensure audit readiness for CMS

• RADV, internal, and external audits.

• Review audit findings and lead remediation efforts, education initiatives, and

• process improvements.

• Ensure adherence to regulatory requirements, internal policies, and documentation standards.

Cross-Functional Collaboration

• Collaborate with Clinical leadership to align documentation practices with coding requirements.

• Partner with Analytics to monitor coding performance, trends, and financial impact.

• Support Operations and Program Management teams to align coding workflows with Risk Adjustment initiatives.

• Provide executive-level reporting and insights related to coding performance and risk capture.

Process Improvement & Governance

Identify opportunities to improve coding efficiency, accuracy, and scalability Implement tools, technology, and workflow enhancements to support coding

operations

Establish governance structures, escalation pathways, and decision-making

frameworks

Ensure consistency of coding practices across markets, programs, and vendors.

Qualifications Education & Certification

• Bachelor’s degree required (health information management, nursing, or related field preferred)

• Active Risk Adjustment–related coding certification required, such as:

• CRC (Certified Risk Adjustment Coders

• CCS (Certified Coding Specialist)

• CPC (Certified Professional Coder) with demonstrated Risk Adjustment expertise

Experience

• Minimum of 7–10 years of progressive healthcare coding experience, with a strong focus on Risk Adjustment.

• At least 5 years of leadership experience managing certified coding teams and/or vendors.

• Demonstrated experience supporting Medicare Advantage Risk Adjustment programs.

• Proven success in audit readiness, compliance oversight, and performance improvement.

Preferred Qualifications

• Experience in value-based care, managed care, or Medicare Advantage organizations

• Experience leading both internal and outsourced coding models

• Strong understanding of CMS Risk Adjustment, HCC models, and audit requirements

• Ability to translate regulatory guidance into operational execution

• Clinical documentation expertise

‎ 

Compensation:

to