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.