Quality Coding Program Manager

Come Grow With Us At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges. Working at Gold Coast Health Plan means working alongside a team of committed individuals who are reshaping the organization and redefining how the needs of the whole person – health, health care, and social services and supports – are met.

We are seeking collaborators, innovators, and those who are driven to be their very best. If you are looking for a career of purpose and are passionate about having an impact on society’s health care challenges, then Gold Coast Health Plan is where you should be. Here, you will be challenged and rewarded in equal measure.

Reasonable Accommodations Statement To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

This position is open to California residents only.

• Develop and maintain a Quality Coding work-plan and convene committees and work groups to drive and oversee risk adjustment work.
• Responsible for implementation and oversight of quality coding related initiatives and projects.
• Partner with internal teams and associated external vendor partners to monitor program and vendor performance, facilitate oversight and performance improvement activities as needed.
• Collaborate with internal and external teams to ensure complete, accurate, timely and compliant reporting of risk adjustment data in accordance with Centers for Medicare and Medicaid Services (CMS) requirements.
• Coordinate, develop and analyze key indicators and other performance data and reporting tools related to the risk adjustment operations and performance to inform leadership on progress of activities and quality coding programs.
• Partner with internal stakeholders and/or external vendors in the definition, design, implementation, and maintenance of data files and data extracts to meet reporting needs.
• Apply and maintain knowledge of applicable current and proposed laws, regulations, and CMS guidance applicable to risk adjustment specifically, and general knowledge of Medicare Advantage and ACA/Exchange based requirements.
• Collaborate with Network Performance, Compliance and other teams to deliver provider and staff education to facilitate clinical documentation improvement and improve performance and outcomes.
• Review/audit medical record documentation to validate reported diagnoses and ensure adherence to CMS Risk Adjustment data submission requirements and documentation standards.
• Support CMS RADV audit readiness activities, including chart validation reviews, mock audits, record retrieval efforts, documentation reconciliation, and regulatory submissions.
• Identify trends, compliance risks, and audit findings through analysis of coding, documentation, provider and vendor performance data.
• Partner closely with Finance to forecast risk adjustments and track impact of coding quality.
• Potential travel for auditing purposes.
• Other duties as assigned.

Education:

• Bachelor’s degree in Health Information Management, Healthcare administration, Public Health or a related field (required).
• Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), or Certified Coding Specialist (CCS)
• Knowledge of Industry standard ICD-10-CM and CPT coding principles.

Experience:

• 3–5 years of experience in medical coding, risk adjustment, HCC coding, coding audits, and provider education.
• Strong…