Overview

HealthEdge® offers AI-powered operational infrastructure for health insurance companies, guaranteeing an enduring financial edge in an increasingly competitive market. We're experiencing strong market momentum, with a growing number of health plans choosing HealthEdge to modernize their operations and compete more effectively. As we expand, we're investing in the people who power that growth, making this a pivotal moment to join us and shape the future of healthcare technology. Learn more at HealthEdge.com.

The Manager, Coding Quality and RADV Audits provides strategic leadership, operational oversight, and execution for assigned business functions, with primary responsibility for CMS audit activities supporting Medicare Advantage and Commercial lines of business. This position leads the planning, coordination, and execution of CMS-mandated Risk Adjustment Data Validation (RADV) audits. The Manager operates within broad organizational objectives to optimize the effective use of people, processes, technology, and financial resources. This role provides strategic direction, develops operational plans, drives continuous improvement, and ensures compliance with applicable regulatory requirements and organizational standards.

Key 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.

Leadership & People Management

Directly supervise exempt and non-exempt employees, including professional and non-professional staff, in accordance with company policies and applicable federal and state laws. Responsibilities include:

• Interviewing, selecting, hiring, onboarding, and training employees.
• Planning, assigning, prioritizing, and directing work.
• Establishing performance expectations and conducting performance evaluations.
• Coaching, developing, recognizing, and counseling employees.
• Provides strategic and tactical initiatives to support improved quality coding reporting.
• Addressing employee concerns, resolving workplace issues, and supporting a positive work environment.
• Managing staffing levels, resource allocation, and departmental capacity.
• Supporting employee engagement, professional development, and continuous learning.
• Promoting collaboration, accountability, innovation, and high performance across the team.

Develops and interprets policies and procedures, recommends changes as appropriate, and provides relevant feedback to the senior management team to meet department and organizational goals with respect to comprehensive and accurate coding and the technology platforms that support.

Required Qualifications

Education

A bachelor’s degree is preferred; however, candidates with a clinical license and extensive relevant experience will be considered in lieu of degree. Commitment to continuous professional development and learning in accordance with the Company’s learning philosophy. Coding certification. Acceptable licensed certifications: CPC, COC, or CRC from AAPC, or CCS or CCS-P from AHIMA.

Experience

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 that provides the necessary knowledge, skills and abilities. Experience within the healthcare payer industry, including health plans, third-party administrators, benefits consulting, or healthcare technology organizations. Demonstrated experience leading complex, enterprise-level projects, programs, or regulatory initiatives. Experience with Medicare Advantage, Commercial health plans, risk adjustment, RADV audits, IVA, or related CMS compliance activities strongly preferred. Demonstrated knowledge and practical experience with CMS regulations and requirements.

Knowledge, Skills & Abilities

• Strong knowledge of healthcare payer operations, industry practices, and regulatory requirements.
• Proven ability to manage competing priorities while understanding the downstream impact of changes to timelines, resources, and deliverables.
• Demonstrated ability to lead large-scale initiatives and deliver complex projects within enterprise environments.
• Strong capability in defining, prioritizing, and communicating business requirements and evaluating solutions against organizational needs.
• Excellent organizational, analytical, written, verbal, and presentation skills.
• Proven ability to facilitate collaboration and achieve results within a matrixed organizational environment.
• Demonstrated ability to drive cross-functional coordination, alignment, and accountability around strategic initiatives.
• Strong relationship-building and stakeholder-management skills, with the ability to effectively partner with senior leaders and functional teams.
• Demonstrated leadership, coaching, team building, and employee development capabilities.
• Ability to establish effective workflows, manage multiple projects simultaneously, and consistently meet deadlines.
• Strong problem-solving and decision-making skills, with the ability to address complex issues and develop practical, sustainable solutions.
• Ability to communicate complex information clearly and effectively through verbal and written communication.
• Proficiency with Microsoft Word, Excel, and PowerPoint required.
• Experience with Microsoft Project preferred.
• Experience with JIRA or similar project-management tools preferred.

Geographic Responsibility

Remote, US

Type of Employment

Full-time, permanent

FLSA Classification (USA Only)

Exempt

Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job: The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus. Work across multiple time zones in a hybrid or remote work environment. Long periods of time sitting and/or standing in front of a computer using video technology. May require travel dependent on company needs. The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990. Candidates may be required to go through a pre-employment criminal background check. HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities.

#LI-Remote

The annual US base salary range for this position is $108,000 to $120,000. This salary range may cover multiple career levels at HealthEdge. Final compensation will be determined during the interview process and is based on a combination of factors including, but not limited to, your skills, experience, qualifications and education.