Director of Quality Audit Coding

Job Description

Job Description

We are seeking an experienced coding quality leader to join our team as Director of Quality Audit Coding, leading the coding audit and quality assurance function across client engagements spanning hospital and professional service lines.

This individual will serve as a subject matter expert in clinical coding quality and compliance, owning the audit methodology, accuracy standards, and remediation programs grounded in the ICD-10-CM/PCS Official Guidelines for Coding and Reporting, AHA Coding Clinic, and AHIMA Standards of Ethical Coding that protect revenue integrity and reduce regulatory exposure across client engagements.

The Director will partner with client stakeholders to evaluate current-state coding quality, validate hospital and professional coding accuracy, and translate audit findings into education, workflow, documentation, and competency improvements that strengthen mid-cycle as well as front- and back-end performance.

This role directly leads the onshore coding audit and quality team, maintains independent audit methodology and scoring, and serves as the escalation point for complex coding, denial, and external audit issues. The Director collaborates with Hospital Billing and Professional Billing leaders, Education and Workforce Development, client partners, and global delivery leadership while retaining onshore-only staff management responsibility.

This leader will serve as a key driver of sustainable coding quality improvement, shaping Healthrise's audit standards and helping scale coding quality capabilities across a diverse client portfolio.

Duties and Responsibilities

Coding Quality Audit Program Leadership

• Knows, understands, incorporates, and demonstrates the Healthrise Core Values in all interactions with team members, clients, and stakeholders.

• Design, lead, and continuously improve coding quality audit programs across facility and professional services using industry-standard methodology, including statistically valid random sampling, risk-based targeted samples, prospective and retrospective reviews, and code-level, record-level, and DRG-level accuracy scoring.

• Establish coding accuracy standards aligned to industry benchmarks (95% or greater or client-defined targets), with defined error categories, financial impact measurement, and routine auditor inter-rater reliability (IRR) testing.

• Own independent audit methodology, sampling plans, scoring criteria, and re-audit protocols across Hospital Billing and Professional Billing operations.

• Perform and oversee detailed coding quality audits across facility and professional services to identify compliance risks, revenue leakage, and process inefficiencies.

• Validate inpatient coding accuracy, including MS-DRG and APR-DRG assignment, principal diagnosis selection, POA indicators, and SOI/ROM capture.

• Audit outpatient and professional coding for accuracy and alignment with CPT, HCPCS, ICD-10-CM, AMA E/M guidelines, modifier usage, NCCI edits, MUEs, and payer-specific requirements.

• Analyze documentation, coding patterns, DRG change rates, case mix index trends, and audit error categories to identify root causes of inaccuracy and revenue variance.

• Develop structured audit findings, gap analyses, and prioritized recommendations aligned to regulatory guidance and industry best practices.

• Ensure audit practices adhere to AHIMA Standards of Ethical Coding, with documented audit policies, auditor qualifications, and complete audit trails.

• Lead auditor calibration and inter-rater reliability activities to validate consistency of interpretation, scoring, error classification, and feedback.

Team and Vendor Leadership

• Lead, develop, and manage the onshore coding quality audit team, including hospital billing and professional billing auditors.

• Partner with global delivery and third-party leaders to evaluate coding and audit quality, SLA performance, remediation evidence, and escalations without assuming direct people-management responsibility for offshore staff.

• Own audit staffing and capacity planning in partnership with operational and client leadership.

• Serve as the primary escalation point for high-complexity or high-risk coding quality issues raised by auditors, managers, or client stakeholders.

• Deliver targeted coder education and feedback based on audit results, including rebuttal and reconciliation processes, focused re-reviews, and follow-up audits to confirm improvement.

• Drive standardization of coding policies, audit workflows, and training curricula across sites and client engagements.

• Partner with Coding Education and Workforce Development to convert audit findings into targeted coaching, competency interventions, retraining, and content updates while maintaining Quality ownership of findings and validation.

Compliance, Denials, and External Audit Response

• Oversee coding compliance alignment with CMS requirements, OIG Compliance Program Guidance, NCCI, payer policies, and other regulatory requirements across DRG, CPT, HCPCS, and ICD-10 coding.

• Lead response to coding-related denials and external audits, including RAC, MAC, payer DRG validation reviews, rebuttal development, and remediation.

• Translate complex regulatory requirements into practical operational guidance and audit criteria.

• Establish and monitor KPIs and dashboards aligned to industry benchmarks, including code-level and DRG-level accuracy, DRG change rate, net financial impact, coding-related denial rate, audit turnaround time, DNFB, and coding backlog.

• Own recurring QA sampling, audit-performance review, denial trend analysis, root-cause actions, and quality reporting.

• Monitor overall and high-risk accuracy against approved client and organizational targets.

• Promptly notify leadership when notable quality concerns, systemic error patterns, or material compliance risks are identified.

Cross-Functional Partnership and Client Delivery

• Partner with client operational leaders, revenue integrity teams, compliance departments, and clinical stakeholders to support adoption of audit-driven recommendations.

• Utilize EHR reporting tools to identify audit targets, validate coding logic, and support data-driven recommendations.

• Evaluate and support implementation of coding audit technology, including computer-assisted coding, AI-assisted coding, and audit tools.

• Support development of executive-level summaries outlining audit results, financial impact, compliance exposure, and remediation roadmaps.

• Maintain project documentation, status updates, issue tracking, and mitigation strategies.

• Travel to client or organizational sites as required to support project execution.

• Perform other duties as assigned.

Qualifications

Required

• Active coding credential such as CCS, CCS-P, CPC, COC, CIC, RHIA, or RHIT (AHIMA or AAPC), or equivalent.

• Minimum seven years of progressive coding experience, including at least three years leading coding audit or quality assurance teams.

• Demonstrated hands-on coding and coding audit experience.

• Experience building or managing coding quality assurance and compliance audit programs, including statistically valid sampling, code-level and DRG-level accuracy scoring, and inter-rater reliability testing.

• Expert knowledge of ICD-10-CM/PCS Official Guidelines for Coding and Reporting, AHA Coding Clinic, CPT, CPT Assistant, HCPCS, MS-DRG and APR-DRG methodologies, NCCI edits, and related CMS and OIG requirements.

• Working knowledge of AHIMA Standards of Ethical Coding and AHIMA/ACDIS compliant query practice guidelines.

• Demonstrated experience directly leading onshore coding audit or quality teams and collaborating with global delivery or third-party partners.

• Strong project management skills with the ability to manage multiple initiatives and workstreams simultaneously.

• Ability to interpret data and translate findings into actionable operational recommendations.

• Strong written and verbal communication skills with the ability to present findings to operational and executive stakeholders.

• Completion of regulatory and mandatory certifications as required.

• Willingness and ability to travel to client or organizational sites as needed, minimum quarterly travel.

Preferred

• Master's degree (MHA, MBA, or equivalent).

• Audit or compliance credential such as CPMA or CPCO.

• CPC, CRCP, FHFMA, or equivalent industry certification.

• Experience using PEPPER reports, the OIG Work Plan, and payer audit trends to drive risk-based audit planning.

• Lean Six Sigma Green Belt or Black Belt certification.

• Experience with AI and automation tools applied to revenue cycle operations.

• Familiarity with the No Surprises Act, price transparency requirements, and other emerging healthcare regulations affecting hospital and physician billing.

Physical Demands and Work Environment

Work Environment

Operates in a variety of professional settings including corporate offices, client hospitals and health system campuses, remote home offices, and travel environments. Must be comfortable adapting to new physical and technological environments quickly and frequently.

Physical Demands

This is largely a sedentary role; however, employees may need to use keyboards, a mouse, and other devices for typing, clicking, and navigating software systems.

Schedule

Standard business hours with flexibility required during crisis deployments, go-live activations, or client-driven escalations. Occasional evening or weekend availability may be required in high-urgency situations.