Director, Payment Integrity and Clinical Coding

EmblemHealth; New York (NY); Remote; USD 113,000 - 211,000; Full time

Job summary

EmblemHealth is seeking a senior leader to oversee Coding Integrity and Provider Reimbursement within the Payment Integrity organization. The role drives enterprise-wide coding strategy, policy creation, and cross-functional collaboration to meet regulatory standards and optimize costs.

Responsibilities include leading initiatives, developing guidelines, forecasting financial impact, and mentoring teams to deliver standardized processes across vendors and internal groups.

Qualifications

• Proven leadership and strategic management experience.
• Strong communication and presentation skills.
• In-depth knowledge of coding, reimbursement, and regulatory methods.
• Ability to develop training and onboarding for teams.

Responsibilities

• Provide enterprise-wide strategic leadership for Coding Integrity and Provider Reimbursement teams.
• Oversee operations, policies, and procedures to align with plan standards and regulatory requirements.
• Lead coding strategy to achieve savings targets and ensure compliance across programs.
• Drive implementation of coding-related programs and measure financial impact of policy changes.
• Mentor team members and foster collaboration and continuous learning.
• Ensure adherence to federal, state, and local regulations.

Skills

Leadership

Communication

Regulatory knowledge

Healthcare reimbursement

Education

Bachelor's Degree

Certified Coder (CPC, CIC, CIMC)

Tools

MS Office

Job description

REMOTE

Summary of Position

• Provide enterprise-wide strategic leadership for the Coding Integrity and Provider Reimbursement teams within the Payment Integrity organization.
• Oversee departmental operations, policies, and procedures to ensure alignment with health plan standards and compliance with federal and state regulatory requirements.
• Serve as the organization's lead coding resource, advising cross-functional leaders and driving performance across internal and external programs.

Principal Accountabilities

• Lead coding strategy and execution to achieve gross and incremental savings targets.
• Lead the development and enterprise-wide management of clinical coding guidelines, including the creation, maintenance, and alignment of policies with industry standards and regulatory requirements. Ensure a structured and compliant approach to coding integrity across all lines of business.
• Drive enterprise-wide operational efficiency and cost-effectiveness by leading the full lifecycle of strategic policy and coding initiatives-from development and approval through implementation and communication. Evaluate and forecast the financial impact of coding and policy changes to deliver measurable medical cost savings.
• Serve as the primary coding advisor across the enterprise, ensuring consistency and compliance.
• Lead implementation and expansion of coding-related programs, including cost-benefit analysis.
• Identify and implement improvements in systems, procedures, and workflows.
• Monitor provider abrasion and drive reductions in appeal rates and recovery adjustments.
• Deliver standardized operational processes across vendors and internal teams.
• Provide mentorship and guidance to team members, fostering a culture of collaboration, innovation, and continuous learning.
• Ideate and identify new opportunities for program growth and optimization.
• Ensure adherence to applicable federal, state, and local regulations.
• Perform other related tasks/projects as directed, requested, or required.

Qualifications

Education, Training, Licenses, Certifications

• Bachelor's Degree required.
• Certified Coder (ex., CPC, CIC, CIMC)

Relevant Work Experience, Knowledge, Skills, and Abilities

• 10 - 12+ years of relevant, professional work experience. (Required)
• 5+ years of staff/process management experience in health care or reimbursement/coding methods, preferably within a managed care environment. (Required)
• 5+ years' experience in ICD-10 & CPT-4 coding w/certification in AAPC or AHIMA for direct oversight of coding functions. (Required)
• Demonstrated in-depth knowledge of state and federal regulations and CMS reimbursement methods. (Required)
• Demonstrated experience in the development and delivery of employee training/development. (Required)
• Excellent communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences. (Required)
• Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.). (Required)
• Outstanding attention to detail and organizational, quantitative, and analytical abilities. (Required)

Additional Information

• Requisition ID: 1000003399
• Hiring Range: $113,400-$210,600