Director, Quality, Clinical Coding and Documentation

Accountabilities: Own HEDIS and Medicare Advantage Star Ratings strategy and performance, establishing annual targets, prioritizing measures, monitoring results, and driving accountability across clinics and payer relationships.

Lead end-to-end quality gap closure, including gap identification, prioritization, outreach campaigns, scheduling strategies, standing orders, care team workflows, and closed-loop completion tracking.

Embed quality improvement into everyday clinical operations through pre-visit planning, team huddles, point-of-care prompts, post-visit follow-up, and other scalable workflows.

Oversee supplemental data strategy and NCQA HEDIS submissions, ensuring source data, clinical documentation, payer files, and submissions are accurate, complete, and auditable.

Manage the annual quality calendar, including specification changes, roadmap planning, performance reviews, chart retrieval, and year-end close.

Serve as a key point of contact for payer partners on quality performance, gap reconciliation, joint operating discussions, and quality incentive initiatives.

Ensure quality measure exclusions are applied appropriately and supported by documented clinical circumstances rather than being used solely to improve performance rates.

Integrate quality, risk adjustment, and documentation strategies so clinicians receive coherent expectations and patient encounters address multiple needs without unnecessary duplication.

Own the end-to-end risk adjustment program, including prospective and retrospective coding, HCC capture and recapture, suspect-condition management, documentation priorities, and performance monitoring under CMS-HCC V28.

Establish targets and reporting for RAF accuracy, condition recapture, suspect-condition closure, coding accuracy, and related financial and operational outcomes.

Design and lead the clinical documentation integrity program, including compliant provider queries, chart review standards, feedback processes, documentation expectations, and problem-list stewardship.

Direct internal coding audits, including sampling methodology, audit cadence, accuracy thresholds, root-cause analysis, corrective actions, and continuous improvement.

Lead RADV and payer audit readiness and response activities, including medical record retrieval, documentation defensibility reviews, attestations, appeals, remediation, and external audit coordination.

Ensure compliance with CMS risk adjustment guidance, ICD-10-CM coding standards, Medicare Advantage data validation requirements, HIPAA, applicable fraud and abuse requirements, and internal compliance policies.

Build and deliver clinician education on documentation specificity, HCC concepts, coding requirements, query response, quality measures, and common documentation gaps relevant to older women.

Provide individualized performance feedback and serve as a trusted resource for physicians and advanced practice clinicians on clinical documentation questions.

Partner with clinical informatics and technology teams to optimize EHR templates, quality and coding prompts, suspecting logic, registries, and workflows that improve accuracy while minimizing clinician burden.

Evaluate and manage quality, coding, NLP, risk adjustment, delegated coding, and outreach vendors, establishing clear service and accuracy expectations.

Develop dashboards, scorecards, and root-cause analytics that make quality performance, care gaps, coding accuracy, and operational trends visible at organizational, clinic, and clinician levels.

Monitor encounter data flows, payer submissions, error rates, and acceptance to ensure complete and reliable data.

Build, hire, develop, and lead a multidisciplinary team spanning quality, coding, CDI, and clinician education, establishing productivity, quality, credentialing, and reliability standards.

Develop scalable playbooks, training resources, policies, and procedures that can support expansion into additional markets.

Represent quality, coding, documentation, and risk adjustment performance to executive leadership, board stakeholders, payer partners, and cross-functional teams.

Champion an environment grounded in integrity, clinical credibility, accountability, collaboration, continuous improvement, and accurate representation of patient needs.

Requirements:

Bachelor’s degree in health information management, nursing, healthcare administration, or a related field; equivalent relevant experience may be considered.

Active coding certification such as CPC, CRC, CCS, CCS-P, RHIA, or RHIT; CRC certification is strongly preferred.

At least 7 years of progressive experience in medical coding, risk adjustment, or clinical documentation integrity, including 3+ years in a leadership or program ownership capacity.

Deep working knowledge of the CMS-HCC risk adjustment model, including the transition from V24 to V28 and its practical implications for documentation and coding.

Demonstrated experience building or substantially redesigning a risk adjustment or CDI program rather than simply managing an established program.

Direct experience with RADV or payer audit response, including medical record retrieval and defensibility review.

Strong knowledge of ICD-10-CM Official Guidelines, Medicare Advantage risk adjustment validation requirements, and compliant provider query practices.

Demonstrated ownership of HEDIS and Medicare Advantage Star Ratings programs, including measure strategy, gap closure, supplemental data, NCQA submission, and measurable performance outcomes.

Working knowledge of NCQA HEDIS technical specifications and CMS Star Ratings methodologies and weighting changes.

Proven ability to educate, influence, and build trust with physicians and advanced practice clinicians.

Strong understanding of EHR systems, reporting tools, healthcare data, and analytics, with the ability to identify trends and translate insights into action.

Strong systems-thinking skills and the ability to connect clinical workflows, documentation, coding, quality measures, data, financial outcomes, and audit requirements.

High integrity and sound judgment, including the willingness to challenge unsupported coding or documentation even when doing so may have financial implications.

Strong operational follow-through and the ability to move programs from strategy through execution, measurement, and continuous improvement.

Excellent communication, facilitation, teaching, and stakeholder-management skills.

Comfortable operating in a high-growth environment where processes and infrastructure may need to be created or significantly improved.

Preferred: Experience in value-based, capitated, or full-risk primary care, particularly within Medicare Advantage or senior-focused populations.

Preferred: Clinical background such as RN or LPN in addition to coding credentials.

Preferred: CDI certification such as CDIP, CCDS, or CCDS-O.

Preferred: Experience in high-growth or multi-site healthcare organizations where infrastructure was built alongside operations.

Preferred: Experience with CAHPS, HOS, patient experience improvement, or formal quality improvement methodologies such as CPHQ, Lean, Six Sigma, or IHI.

Preferred: Experience serving geriatric or women’s health populations.

Benefits:

Full-time, exempt Director-level position.

Hybrid work opportunity in the Twin Cities metro, with regular in-person time across clinic locations; remote arrangements may be considered with travel into the market as needed.

Opportunity to play a significant leadership role in a growing, mission-driven healthcare organization focused on improving care for women aged 65+.

Direct exposure to executive leadership, payer partners, clinical operations, population health, and cross-functional strategic initiatives.

Opportunity to build and scale quality, coding, CDI, and risk adjustment infrastructure rather than simply maintain existing programs.

Meaningful scope across quality performance, clinical documentation, risk adjustment, compliance, analytics, technology, clinician education, and team leadership.

Occasional travel between clinic locations, with limited travel for conferences, payer meetings, or new market launches.

Support for professional development and continuous learning in quality, coding, risk adjustment, and healthcare operations.

A collaborative environment centered on patient impact, clinical credibility, continuous improvement, accountability, and teamwork.

Confidential handling of protected health information is required, with work conducted in accordance with applicable compliance and privacy standards.

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