Manager, Compliance, Medical Coding

Manager, Compliance, Medical Coding

Support Health Plan Risk Adjustment operations through government audit readiness, compliance oversight, and internal quality assurance reviews. Perform coding validation, documentation review, and data-driven analysis to ensure accurate risk capture, regulatory compliance, and coding integrity. Partner with operational, clinical, and compliance teams to identify risks, improve coding quality, support audit activities, and drive continuous improvement across Risk Adjustment programs.

In addition to the responsibilities listed below, the position is also responsible for serving as a compliance subject matter expert related to coding functions, managing and directing audit activity related to coding within all settings of care, ensuring compliance with national coding policies and procedures, assisting with escalated coding questions and related topics, developing and presenting coding educational inservices and seminars, and evaluating the quality of coding assignments across all lines of business. Additionally, this position is responsible for developing the annual coding audit plan in collaboration with reimbursement compliance teams, developing and reviewing reports of audit results, helping set the direction for coding and focused projects related to audit outcomes, and supporting compliance and the Principles of Responsibility (KPs code of conduct).

Essential Responsibilities:

• Pursues professional growth and provides developmental opportunities for others by soliciting and acting on performance feedback; building collaborative, cross-functional relationships; training and developing talent for growth opportunities; delegating tasks and decisions; fostering open dialogue amongst team members; executing performance management guidelines and expectations; and working closely with employees to set goals and provide open feedback and coaching to drive performance improvement.
• Manages designated work unit by translating business plans into tactical action items; ensuring all policies and procedures are followed; delegating tasks to meet goals and objectives; overseeing the completion of work assignments; aligning team efforts; building accountability for and measuring progress in achieving results; identifying and addressing improvement opportunities; removing obstacles that impact performance; and guiding performance and developing contingency plans accordingly.
• Manages company compliance activities by partnering with internal and external stakeholders; applying established regulations and standards to compliance efforts; managing the design, development, and execution of strategic compliance initiatives; overseeing the analysis of regulations and regulatory changes, and their application to operations; and overseeing the documentation of compliance activities.
• Manages compliance reporting efforts across one or more business functions by managing the evaluation and summary of compliance data, audit information, and potential risks and remedies; identifying and reporting key compliance drivers, liabilities, and performance indicators (for example, adherence to standards, incorporation of new regulations) to senior management; and developing complex presentations to convey key findings to leadership and external business stakeholders.
• Manages compliance investigations across one or more business functions by managing the collection and analysis of quantitative and qualitative data; leading interviews as appropriate; researching key business issues; and evaluating and recommending corrective action plans for substantiated allegations.
• Manages projects or compliance components of larger cross-functional projects by identifying and managing stakeholder contacts; assembling teams based on project needs and team member strengths; developing, analyzing, and managing project plans; negotiating and managing project schedules and resource forecasts; and managing project financials and deliverables.
• Manages activities associated with continued regulatory compliance for one or more business functions by monitoring, interpreting, and designing strategy around regulatory changes; determining the impact of changes to the business; providing direction on implementation of changes throughout the organization; and providing regulatory input before and during inspections to minimize the risks of future non-compliance.
• Manages the implementation of compliance efforts by approving compliance requirements; ensuring the assessment of current state compliance to identify gaps and corrective actions; managing the analysis and development of complex compliance standards, policies and procedures, and training; and ensuring and monitoring ongoing compliance adherence.

Minimum Qualifications:

• Minimum five (5) years medical coding experience.
• Minimum two (2) years experience in a leadership role with or without direct reports.
• Bachelors degree in Health Care Administration, Clinical, Law, Public Health, Business or related field and Minimum six (6) years experience in health care compliance, health care operations (quality, risk, etc.), audit, finance, regulatory or public policy development, investigations, information security, or insurance/health plan governance or a directly related field. Additional equivalent work experience in a directly related field may be substituted for the degree requirement.
• Certified Risk Adjustment Coder from American Academy of Professional Coders OR Certified Coding Specialist from American Health Information Management Association OR Certified Professional Coder from American Academy of Professional Coders

Preferred Qualifications:

• Five (5) years hospital coding experience.
• Five (5) years coding audit experience.