Manager, Coding Quality – RADV Audits

• Provide strategic leadership, planning, project coordination, and operational oversight for CMS-mandated RADV audits across Medicare Advantage and Commercial lines of business
• Develop and implement audit strategies, workflows, processes, and performance objectives
• Establish priorities and balance departmental workloads to maximize productivity, quality, efficiency, and resource utilization
• Direct departmental operations, including planning, problem-solving, staff development, performance management, and organizational communication
• Translate business and regulatory requirements into actionable objectives and measurable outcomes
• Identify process-improvement and operational-efficiency opportunities and implement sustainable solutions
• Provide executive-level and cross-functional leadership for strategic initiatives and regulatory activities
• Lead special projects, initiatives, and complex problem-resolution efforts
• Monitor departmental performance, identify trends and risks, and implement corrective actions
• Foster partnerships across business, clinical, compliance, technology, and operational teams
• Ensure departmental activities align with CMS regulations, company policies, contractual requirements, and industry standards
• Supervise exempt and non-exempt employees
• Interview, select, hire, onboard, and train employees
• Plan, assign, prioritize, and direct work
• Establish performance expectations and conduct performance evaluations
• Coach, develop, recognize, and counsel employees
• Support improved quality coding reporting
• Address employee concerns and resolve workplace issues
• Manage staffing levels, resource allocation, and departmental capacity
• Develop and interpret policies and procedures and recommend changes to senior management

Requirements

• Bachelor’s degree preferred; candidates with a clinical license and extensive relevant experience may be considered in lieu of degree
• Required coding certification: CPC, COC, or CRC from AAPC, or CCS or CCS-P from AHIMA
• Minimum of 7 years of experience in risk adjustment programs
• Minimum of 3 years of management experience in a medical coding quality assurance environment with demonstrated technical experience
• Experience within the healthcare payer industry, including health plans, third-party administrators, benefits consulting, or healthcare technology organizations
• Experience leading complex, enterprise-level projects, programs, or regulatory initiatives
• Knowledge and practical experience with CMS regulations and requirements
• Proficiency with Microsoft Word, Excel, and PowerPoint required
• Experience with Microsoft Project preferred
• Experience with JIRA or similar project-management tools preferred
• Ability to work across multiple time zones in a hybrid or remote work environment
• May be required to pass a pre-employment criminal background check
• Must meet physical demands including extended periods sitting and/or standing at a computer

Core Competencies

Demonstrates expertise in strategic leadership and operational oversight for CMS-mandated RADV audits, with a strong focus on developing audit strategies and ensuring compliance with regulatory requirements. Proven ability to manage departmental performance, foster cross-functional partnerships, and implement process improvements in the healthcare payer industry.

Highest-signal resume keywords

• Risk Adjustment Programs
• Management Experience in Medical Coding Quality Assurance
• CMS Regulations and Requirements
• Coding Certification (CPC, COC, CRC, CCS, CCS-P)
• Project Management Tools (JIRA, Microsoft Project)

ATS Optimization Keywords

Hard Skills

• Risk Adjustment Programs
• Management Experience in Medical Coding Quality Assurance
• CMS Regulations and Requirements
• Coding Certification (CPC, COC, CRC, CCS, CCS-P)
• Project Management
• Process Improvement
• Operational Efficiency
• Performance Management
• Data Analysis
• Quality Assurance

Soft Skills

• Strategic Leadership
• Problem-Solving
• Organizational Communication
• Employee Development
• Cross-Functional Collaboration

Certifications & Qualifications

• CPC
• COC
• CRC
• CCS
• CCS-P

Industry Keywords

• Healthcare Payer Industry
• Medicare Advantage
• Commercial Lines of Business
• Audit Strategies
• Regulatory Initiatives

Tools & Technologies

• Microsoft Word
• Microsoft Excel
• Microsoft PowerPoint
• Microsoft Project
• JIRA