Remote Leader: Coding Quality & RADV Audits

F-Prime Capital; United States; On-site; USD 108,000 - 120,000; Full time

Job summary

HealthEdge is seeking a Manager, Coding Quality & RADV Audits to lead CMS RADV audits for Medicare Advantage and Commercial lines. You will drive audit strategies, coordinate cross-functional teams, and ensure regulatory compliance across CMS requirements.

The role requires 7+ years in risk adjustment and 3+ years in coding quality management, with strong leadership and project management skills. Remote US work is supported; base salary ranges with incentives are provided.

Qualifications

• Bachelor’s degree preferred; however, candidates with a clinical license and extensive relevant experience will be considered in lieu of degree
• Coding certification. Acceptable licensed certifications: CPC, COC, or CRC from AAPC, or CCS or CCS-P from AHIMA.
• Minimum of Seven (7) years of experience in risk adjustment programs is required.
• Minimum of three (3) years of management experience in a medical coding quality assurance environment with demonstrated technical experience
• Experience within the healthcare payer industry, including health plans, third-party administrators, or healthcare technology organizations.
• Demonstrated knowledge and practical experience with CMS regulations and requirements.

Responsibilities

• Provide strategic vision, leadership, planning, project coordination, and operational oversight for the execution of CMS-mandated RADV audits across Medicare Advantage and Commercial lines of business.
• Lead the development and implementation of audit strategies, workflows, processes, and performance objectives to support regulatory compliance and organizational goals.
• Establish priorities and balance departmental workloads to maximize productivity, quality, efficiency, and resource utilization.
• Direct departmental operations, including planning, problem-solving, staff development, performance management, and organizational communication.
• Translate business and regulatory requirements into actionable operational objectives and measurable outcomes.
• Identify opportunities for process improvement, operational efficiency, and lead initiatives to implement sustainable solutions.
• Provide executive-level and cross-functional leadership for strategic initiatives and regulatory activities.
• Lead special projects, initiatives, and complex problem-resolution efforts as assigned.
• Monitor departmental performance, identify trends and risks, and implement corrective actions as appropriate.
• Foster strong partnerships across business, clinical, compliance, technology, and operational teams to ensure successful execution of organizational priorities.
• Ensure departmental activities align with applicable CMS regulations, company policies, contractual requirements, and industry standards.

Skills

CMS RADV audits

Risk Adjustment

Leadership

Stakeholder management

Project management

JIRA

Microsoft Project

Excel

PowerPoint

Word

Education

Bachelor's degree preferred

Clinical license acceptable in lieu of degree

Coding certification (CPC/COC/CRC/CCS/CCS-P)

Tools

JIRA

Microsoft Project

Job description

HealthEdge is seeking a Manager, Coding Quality & RADV Audits to lead CMS RADV audits for Medicare Advantage and Commercial lines. You will drive audit strategies, coordinate cross-functional teams, and ensure regulatory compliance across CMS requirements.

The role requires 7+ years in risk adjustment and 3+ years in coding quality management, with strong leadership and project management skills. Remote US work is supported; base salary ranges with incentives are provided.