From Home Optum Health Coding Risk Adjustment Jobs

PRIMARY FUNCTION
The Director, Coding Integrity & Performance Improvement is an enterprise Revenue Cycle and Clinical Data leadership role responsible for establishing and leading a Coding Center of Excellence (COE) that drives accuracy, compliance, quality, and performance across both Fee-for-Service (FFS) and Risk Adjustment (HCC) coding quality programs.
Reporting to the Senior Vice President of Revenue Cycle Management, this leader is responsible for developing and implementing enterprise coding governance, quality assurance programs, documentation integrity initiatives, and operational discipline aligned with federal regulations, CMS guidelines, and Office of Inspector General (OIG) compliance requirements.
This role ensures the organization maintains the highest standards of coding accuracy, audit readiness, and clinical documentation integrity while optimizing reimbursement, reducing compliance risk, and enabling scalable enterprise growth across multiple lines of business.
ESSENTIAL DUTIES AND RESPONSIBILITIES
This list may not include all of the duties that may be assigned.
1)Establish and lead an enterprise Coding Center of Excellence (COE) across Fee-for-Service and Risk Adjustment coding functions.
2)Define coding governance frameworks, operating models, and performance standards across all business lines.
3)Ensure alignment with CMS guidelines, federal regulations, and OIG compliance expectations.
4)Develop enterprise coding policies, procedures, and audit frameworks to ensure consistency and accountability.
5)Drive operational discipline and standardization across all coding teams and markets.
6)Oversee production coding operations for both FFS and Risk Adjustment (HCC) programs.
7)Develop scalable workflows for accurate, timely, and compliant code assignment.
8)Optimize coding workflows across physician enterprise and value-based care programs.
9)Ensure operational alignment between coding, documentation, and reimbursement models.Design and implement a comprehensive coding quality assurance and auditing program across all lines of business.
11)Establish audit methodology, sampling strategies, and quality benchmarks.
12)Monitor coding accuracy, specificity, and compliance performance at provider, team, and enterprise levels.
13)Identify coding risk areas and implement corrective action plans.
14)Ensure audit readiness for internal, payer, and regulatory reviews.
15)Oversee enterprise clinical documentation integrity initiatives to improve specificity, accuracy, and completeness of provider documentation.
16)Partner with physicians and clinical operations to improve documentation practices supporting both FFS and Risk Adjustment models.
17)Assist with and Co-develop CDI workflows that reduce documentation gaps and coding ambiguity.
18)Support initiatives that enhance HCC capture and quality measure accuracy.
19)Oversee coding compliance programs aligned with federal regulations, CMS requirements, and OIG guidance.
20)Ensure adherence to coding ethics, documentation standards, and audit protocols.
21)Partner with Compliance and Legal teams to support audit defense and risk mitigation strategies.
22)Lead enterprise coding-related denial management and prevention initiatives.
23)Establish a coding denial prevention taskforce to address systemic coding-related denial rivers.
24)Reduce avoidable denials through upstream coding and documentation improvements.
25)Develop feedback loops between coding, billing, and clinical teams.
26)Design and deliver enterprise coding education programs for coders, physicians, and clinical staff.
27)Develop role-based training programs for FFS and Risk Adjustment coding accuracy and compliance.
28)Create standardized training materials, toolkits, and provider feedback reports.
29)Design and coordinate enterprise coding education programs for coders, physicians, and clinical staff on documentation requirements, coding updates and regulatory changes.
30)Support integration of AI-driven coding tools, NLP-based documentation review systems, and automation within EHR/PM systems.
31)Define business requirements for coding optimization tools and workflows.
32)Evaluate and enhance coding efficiency through technology enablement.
33)Develop enterprise-wide coding standard operating procedures (SOPs).
34)Establish governance frameworks for coding policy updates and regulatory changes.
35)Monitor and track Key Performance Indicators (KPIs) such as:
a) Coding

34)Establish governance frameworks for coding policy updates and regulatory changes.
35)Monitor and track Key Performance Indicators (KPIs) such as:
a)Coding Accuracy Rate (FFS & Risk Adjustment)
b)HCC Capture Rate / RAF Score Accuracy as applicable
c)First Pass Claim Acceptance Rate (coding-related)
d)Coding Denial Rate & Reduction Trends
e)Audit Error Rate (internal & external)
f)Documentation Completeness & Quality Scores
g)Under-coded Service Identification & Recovery Impact
h)Provider Documentation Improvement Metrics
i)Coding Productivity Standards
j)Training Completion & Competency Scores
36)Oversee Coding and Clinical Documentation Improvement to ensure compliance with regulations and organizational policies
37)Manage and monitor coding and documentation accuracy, ensuring adherence to best practices and regulatory requirements
38)Collaborate with Information Technology and other departments to implement technology and
39)Lead, mentor, and develop a high-performing team through structured training, coaching, and career development opportunities
40)Other duties as assigned.
SUPERVISORY RESPONSIBILITIES
Oversees a team of Coding Specialist, Coding Compliance Auditors, and Clinical Educators
QUALIFICATIONS
EDUCATION: Master’s Degree in Healthcare Administration, Health Informatics, Business Administration, or related field required
EXPERIENCE: Minimum 10+ years of progressive coding operations experience across Fee-for-Service and Risk Adjustment (HCC) environments.
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Minimum 5 years of experience leading coding quality, auditing, compliance, or education programs.
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Experience in physician enterprise, MSO, health system, or multi-specialty group environment required.
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Demonstrated experience building or leading coding governance or Center of Excellence (COE) models.

Experience supporting risk-based contracting, value-based care, and CMS/HCC programs strongly preferred.
LICENSURE / CERTIFICATION
•Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) required.
•Certified Risk Adjustment Coder (CRC) required.
KNOWLEDGE, SKILLS AND ABILITIES
•In-depth knowledge of federal, state and local regulations regarding medical records, coding, and clinical documentation
•Expertise in coding and billing practices across multiple healthcare settings
•Strong strategic thinking, problem-solving, and leadership skills
•Ability to influence and collaborate with key stakeholders, including physicians, administrators, and IT
•Proficiency in Microsoft Excel, Word, and PowerPoint
•Coding Governance & Compliance Leadership
•Strategic Clinical Data Integrity Management
•Operational Excellence
•Regulatory Interpretation & Risk Management
•Data-Driven Decision Making
•Cross-Functional Collaboration
•Physician Engagement & Education
•Change Management
•Technology & Innovation Adoption
TYPICAL WORKING CONDITIONS
•Non-patient
•May be either full time remote/telework or rotate working in the office and remote/telework
•If remote, this job must be U.S. based.
OTHER PHYSICAL REQUIREMENTS
•Vision
•Sense of sound
•Sense of touch

PERFORMANCE REQUIREMENTS
Ensure compliance with coding and documentation best practices to maintain the integrity of coding and billing practices.
Adhere to all organizational information security policies and protect all sensitive information including but not limited to ePHI and PHI (Protected Health Information) in accordance with organizational policy, Federal, State, and local regulations.