From Home Optum Health Coding Risk Adjustment Jobs in Houston, TX

Job Title: Director, Clinical Documentation Improvement

Supervisor: VP, Market Operations

Required License(s)/ Certification(s): CPC (Certified Professional Coder) or CRC (Certified Risk Adjustment Coder) credential required, or equivalent coding certification. CDEO or RHIA preferred.

FLSA Status: Exempt

Summary:  The Director, Clinical Documentation Improvement is responsible for leading Apex Health Solutions’ risk adjustment and clinical documentation improvement (CDI) strategy across employed and contracted provider engagements. This role owns end-to-end CDI workflow design—from EMR-embedded and portal-driven programs to payer relationship support and compliance oversight. The Director manages a team of CPC-credentialed coders, drives AI-enabled and potential offshore efficiency strategies, and serves as a strategic partner to clients, payers, and internal Apex Medical and Product leadership. This is a high-impact, client-facing leadership role requiring deep expertise in risk adjustment methodology, coding compliance, and provider education.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

Risk Adjustment and Clinical Documentation Improvement Workflows

●       Design, implement, and oversee both employed and contracted CDI workflows, including EMR-embedded and portal-driven program models.

●       Ensure workflow accuracy, compliance, and scalability across diverse client environments and EMR platforms.

Risk Adjustment Strategy Development

●       Develop and execute a comprehensive risk adjustment strategy that drives accurate, specific, and compliant clinical documentation across client provider networks.

●       Lead workflow development for new client onboardings per year, customizing approaches by EMR platform and client operating model.

●       Serve as a client-facing leader, delivering weekly and monthly performance reporting and strategic presentations in partnership with Market Operations leadership.

Team Leadership and Staffing Optimization

●       Recruit, lead, and develop a team of CPC-credentialed coders supporting both embedded and contracted CDI workflows.

●       Scale and optimize the staffing model to meet client growth, including evaluation of AI-assisted coding tools and offshore hiring strategies to drive efficiency.

●       Conduct performance management, annual reviews, and ongoing coaching to develop team capabilities and maintain coding quality standards.

Product Development Partnership

●       Serve as a subject matter expert and internal advocate for CDI workflow enhancements, translating operational insights into actionable product requirements.

●       Partner with key external consultants to develop the data and AI layers supporting coding workflows, including predictive risk capture and documentation gap identification tools.

●       Inform the design and development of audit workflow capabilities to support compliance, accuracy, and revenue integrity.

Provider Education and Audit Workflow

●       Develop and maintain a comprehensive provider education library covering risk adjustment best practices, HCC coding, and documentation specificity.

●       Partner with Apex Medical leadership to align provider education strategies with clinical quality and risk adjustment objectives.

●       Design continuing medical education (CME) offerings that drive provider engagement and support CME credit attainment.

●       Develop and oversee the provider audit workflow to identify documentation gaps, track remediation, and measure improvement over time.

Payer Relationship Support

●       Support the development and management of upstream payer relationships, including national payers such as UnitedHealthcare, Humana, and others specific to risk adjustment scope.

●       Oversee risk adjustment reporting deliverables required by contracted payers, ensuring accuracy, timeliness, and compliance.

●       Lead Annual Supplemental Mapping (ASM) process development and support payer-facing risk adjustment submissions and reconciliation activities.

Compliance and Audit Oversight

●       Establish and maintain a robust compliance framework for all risk adjustment activities, ensuring alignment with CMS guidelines, RADV audit standards, and payer contract requirements.

●       Oversee internal audit processes to monitor coding accuracy, identify risk areas, and implement corrective action plans.

●       Stay current on regulatory changes impacting risk adjustment and CDI, and proactively communicate updates to internal and client-facing stakeholders.

●       Other duties may be assigned.

Candidate Qualifications

●       Deep expertise in risk adjustment methodologies, HCC coding, and CMS risk adjustment models (MA, ACA, PACE).

●       Demonstrated experience managing and scaling teams of certified coders (CPC, CRC, or equivalent credentials).

●       Strong working knowledge of major EMR platforms and CDI workflow integration (e.g., Epic, Athena, eClinicalWorks).

●       Experience developing and delivering provider education programs, including CME-eligible offerings.

●       Ability to build and sustain strong client, payer, and cross-functional stakeholder relationships.

●       Strong analytical skills with the ability to interpret risk adjustment data and translate insights into actionable strategies.

●       Familiarity with AI-assisted coding tools and technology-enabled workflow optimization.

●       Advanced written and verbal communication skills, including experience presenting to executive and client audiences.

●       Knowledge of compliance frameworks governing risk adjustment, including RADV, CMS audits, and payer audit processes.

Education/ Experience

●       Bachelor’s degree in Health Information Management, Healthcare Administration, Nursing, or a related field; Master’s degree preferred.

●       Minimum of 7 years of experience in risk adjustment, clinical documentation improvement, or health plan coding operations.

●       Minimum of 3 years in a people management or team leadership role.

●       Experience working in or alongside a physician practice management, managed care, or value-based care organization preferred.

●       CPC (Certified Professional Coder) or CRC (Certified Risk Adjustment Coder) credential required, or equivalent coding certification. CDEO or RHIA preferred.

Skills

●       Strategic Leadership – Develops and executes multi-faceted strategies that align CDI and risk adjustment operations with organizational growth goals.

●       Achievement Focus – Sets and achieves challenging goals; demonstrates persistence and overcomes obstacles; measures performance against a standard of excellence.

●       Communication – Expresses ideas clearly in both written and verbal form; presents complex data accessibly to diverse audiences.

●       Managing People – Provides clear direction, develops team members, and fosters a high-performance culture.

●       Client Orientation – Builds trusted partnerships with clients and payers; proactively identifies and addresses client needs.

●       Problem Solving – Identifies issues in a timely manner; develops creative solutions; resolves challenges at early stages.

●       Planning & Organization – Prioritizes work effectively; manages multiple client engagements and workstreams simultaneously.

About Apex Health Solutions

Apex Health is a tech-enabled management services organization that enhances the enterprise value of health systems by transforming physician networks into strategic assets. More than a consultant, Apex embeds as a long-term partner to drive sustainable performance across provider enablement, quality, network growth, and value-based care. With proven success at leading health systems, Apex helps clients preserve local control over care delivery and financing, rather than outsourcing it to national insurers.

The above job description is not intended to be an all-inclusive list of duties and standards of the position.  Incumbents will follow any other instructions, and perform any other related duties, as assigned by their supervisor