Director, Quality, Clinical Coding and Documentation
Core
Lead quality, clinical coding, and documentation operations to drive HEDIS/Star Ratings performance and accurate risk adjustment for a women's primary care network.
Role type
Director, Quality & Risk Adjustment
Builds
Quality measure strategies, risk adjustment programs, and clinical documentation integrity workflows
Domain
Healthcare / Medicare Advantage / Women's Primary Care
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure | physical/clinical work
Required skills
HEDIS measure strategy, Star Ratings optimization, risk adjustment (CMS-HCC V28), clinical documentation integrity (CDI), gap closure operations, payer contract management, CPT/HCPCS/diagnosis coding, EHR workflow design, vendor oversight, NCQA submission compliance
Preferred skills
Experience with women's health specific measures (BCS-E, COL-E, OSW, OMW, CBP, diabetes set, COA, TRC, medication adherence), CMS-HCC V28 implementation, advanced illness/frailty exclusion logic
Technologies
EHR systems, NCQA submission platforms, CMS-HCC V28 logic
Responsibilities
Set annual HEDIS and Star Ratings targets and execute gap closure strategies; Own prospective and retrospective risk adjustment programs under CMS-HCC V28; Design and lead CDI programs to ensure accurate coding and documentation; Partner with payers on quality performance and shared savings; Embed quality and coding requirements into daily clinic workflows; Analyze performance data to distinguish care gaps from documentation failures
Seniority
Director, strategic leadership with hands-on operational ownership
