Remote Senior Manager, Clinical & Coding Audits

Health Business Solutions; United States; On-site; USD 120,000 - 180,000; Full time

Job summary

Health Business Solutions is seeking an experienced Senior Manager, Clinical & Coding to lead end-to-end clinical and coding audit operations across government and commercial payers. The role emphasizes post-pay audit quality, regulatory compliance, and driving improvements in documentation, coding, and reimbursement for diverse client portfolios.

You will lead multidisciplinary audit teams in a fast-paced remote environment, manage multiple priorities, and collaborate with stakeholders to

Qualifications

• Bachelor’s degree in Nursing.
• 7+ years of progressive healthcare auditing with focus on clinical and coding post-pay audits.
• 1+ years of experience in people leadership with responsibility for training, coaching, and providing performance feedback.
• Strong working knowledge of CMS regulations, official coding guidelines, and payer audit processes.
• Professional credentials such as RHIA, RHIT, CCS, CCS-P, CPC, CPMA, RN, or equivalent.

Responsibilities

• Lead and oversee clinical and coding audits, including government and commercial payer audits (e.g., RAC, MAC, CERT, PERM, TPE, and commercial payer reviews).
• Direct audit intake, medical record review, clinical validation, coding accuracy assessments, quality assurance, and final deliverables.
• Ensure audits are conducted in accordance with CMS regulations, official coding guidelines, payer policies, and internal compliance standards.
• Provide subject-matter expertise in ICD-10-CM/PCS, CPT, HCPCS, MS-DRG/APR-DRG validation, and clinical documentation integrity.
• Review complex, high-risk audit findings and support defensible, well-documented outcomes.
• Partner with clinical, coding, and appeals teams to support rebuttals, appeals, and education initiatives as needed.
• Manage, mentor, and develop a team of clinical auditors, coding auditors, and audit leads, including onshore and offshore resources where applicable.
• Assign workloads, monitor productivity and quality metrics, and ensure timely completion of audits.
• Foster a culture of collaboration, accountability, and continuous improvement.
• Track audit outcomes, denial trends, and financial impact across clients and payers.
• Develop and present audit performance reports, dashboards, and executive-level summaries.
• Identify systemic risks and recommend proactive strategies to reduce future audit exposure and improve compliance.
• Serve as a senior point of contact for clients, providing guidance on audit strategy, findings, and risk mitigation.
• Collaborate with internal leadership, operations, and clinical teams to align audit activities with organizational goals.
• Support business development efforts by contributing audit expertise to proposals, client discussions, and service enhancements.
• Lead complex DRG denial reviews and appeals, conducting comprehensive clinical and coding validation to identify inaccurate payer determinations, support overturn efforts, and maximize reimbursement recovery for inpatient claims.
• Establish and maintain standardized denial management workflows, audit programs, and escalation processes to improve appeal success rates and reduce future denials.
• Develop and monitor DRG denial metrics, recovery rates, and payer performance dashboards, presenting findings and strategic recommendations to executive leadership.
• Provide expert oversight of clinical documentation, coding practices, and regulatory requirements affecting DRG assignment and reimbursement.

Skills

People leadership

CMS regulations knowledge

Audit management

Analytical thinking

Communication skills

Education

Bachelor’s degree in Nursing

Tools

EHRs

Performance dashboards

Audit tracking systems

Job description

Health Business Solutions is seeking an experienced Senior Manager, Clinical & Coding to lead end-to-end clinical and coding audit operations across government and commercial payers. The role emphasizes post-pay audit quality, regulatory compliance, and driving improvements in documentation, coding, and reimbursement for diverse client portfolios.

You will lead multidisciplinary audit teams in a fast-paced remote environment, manage multiple priorities, and collaborate with stakeholders to