Job Description Summary
The Director, Risk Adjustment Coding (Certified) provides strategic and operational leadership for CareMore’s Risk Adjustment coding function. This role is accountable for the accuracy, integrity, and performance of all Risk Adjustment coding activities across internal teams and external vendors, ensuring alignment with CMS regulations, audit readiness standards, and CareMore’s financial and clinical objectives.
How will you make an impact & Requirements
The Director will lead certified coding teams, establishes coding governance and quality programs, partners cross-functionally with Clinical, Compliance, Operations, Analytics, and Vendor Management, and drives continuous improvement across prospective, concurrent, and retrospective Risk Adjustment initiatives.
Key Responsibilities
Risk Adjustment Coding Strategy & Leadership
Provide enterprise leadership for Risk Adjustment coding strategy across all
programs, including prospective, concurrent, and retrospective reviews.
Establish and maintain standardized coding policies, procedures, and
documentation practices aligned with CMS Risk Adjustment regulations.
Translate Risk Adjustment strategy into scalable coding operations that support accurate RAF capture and audit defensibility.
Serve as the subject matter expert for Risk Adjustment coding interpretation and best practices.
Team Leadership & Development
Lead, mentor, and develop teams of certified Risk Adjustment coders and coding leaders.
Establish productivity, quality, and accuracy benchmarks for internal coding teams.
Foster a culture of accountability, compliance, and continuous learning.
Ensure ongoing coder education related to CMS guidance, ICD-10-CM updates,
and regulatory changes.
Quality, Audit & Compliance Oversight
Design and oversee Risk Adjustment coding quality assurance and audit
programs.
Partner with Compliance and Audit teams to ensure audit readiness for CMS
RADV, internal, and external audits.
Review audit findings and lead remediation efforts, education initiatives, and
process improvements.
Ensure adherence to regulatory requirements, internal policies, and documentation standards.
Cross-Functional Collaboration
Collaborate with Clinical leadership to align documentation practices with coding requirements.
Partner with Analytics to monitor coding performance, trends, and financial impact.
Support Operations and Program Management teams to align coding workflows with Risk Adjustment initiatives.
Provide executive-level reporting and insights related to coding performance and risk capture.
Process Improvement & Governance
Identify opportunities to improve coding efficiency, accuracy, and scalability
Implement tools, technology, and workflow enhancements to support coding
operations
Establish governance structures, escalation pathways, and decision-making
frameworks
Ensure consistency of coding practices across markets, programs, and vendors.
Qualifications
Education & Certification
Bachelor’s degree required (health information management, nursing, or related field preferred)
Active Risk Adjustment–related coding certification required, such as:
CRC (Certified Risk Adjustment Coders
CCS (Certified Coding Specialist)
CPC (Certified Professional Coder) with demonstrated Risk Adjustment expertise
Experience
Minimum of 7–10 years of progressive healthcare coding experience, with a strong focus on Risk Adjustment.
At least 5 years of leadership experience managing certified coding teams and/or vendors.
Demonstrated experience supporting Medicare Advantage Risk Adjustment programs.
Proven success in audit readiness, compliance oversight, and performance improvement.
Preferred Qualifications
Experience in value-based care, managed care, or Medicare Advantage organizations
Experience leading both internal and outsourced coding models
Strong understanding of CMS Risk Adjustment, HCC models, and audit requirements
Ability to translate regulatory guidance into operational execution
Clinical documentation expertise
Compensation:
$144,367.00to
$216,552.00