Director, Quality, Clinical Coding and Documentation
hace 17 días
Nashville
Job Description:\n\nDirector, Quality, Clinical Coding and Documentation - Job Description\nEmployment Type: Full-Time, Exempt\nLevel: Director\nLocation: Twin Cities Metro, MN or remote, with travel into market as needed\nReports To: Chief Medical Officer\nWho We Are:\nAt Herself Health, we're on a mission to help women get more life out of life, together.\nWe're reimagining primary care for women on Medicare by delivering the kind of care they deserve: thoughtful, relationship-centered, and designed specifically for the realities of aging. We believe healthcare should never feel rushed, impersonal, or one-size-fits-all. That's why our care model gives patients more time with their care team and focuses on the health issues that matter most to women later in life—from post-menopausal care and bone health to weight management, preventive care, and mental, emotional, and social well-being.\nWe're building more than a better healthcare experience—we're building a team united by purpose. Every role at Herself Health contributes to creating exceptional experiences for our patients, our teammates, and the communities we serve.\nOur values guide how we work every day:\n\n Her, First – We put women at the center of every decision and every interaction.\n Curious, Always Learning – We ask questions, embrace new ideas, and continuously improve.\n Own It, Act – We take initiative, follow through, and hold ourselves accountable for results.\n Together, Unstoppable – We achieve more through collaboration, trust, and supporting one another.\n\nToday, Herself Health serves women 65+ in five primary care clinics dispersed across the Twin Cities metro of Minnesota. As we continue to grow, we're looking for passionate, mission-driven people who want to help shape the future of healthcare for women.\nAbout the Director, Quality, Clinical Coding and Documentation Operations Role:\nThe Director, Quality, Clinical Coding and Documentation owns the two functions that determine whether Herself Health succeeds under value-based contracts: the quality of care we deliver and can demonstrate, and the accuracy of the clinical documentation and coding that describes our patients. This is a build-and-run role. You will design and lead the programs that drive HEDIS and Star Ratings performance, ensure our documentation accurately reflects the complexity of the women we serve, keep our coding compliant and defensible under audit, and make all of it workable for clinicians rather than burdensome.\nYou will hold accountability for quality measure performance end to end — measure strategy, gap closure operations and outreach, supplemental data and NCQA submission, and reporting to leadership and payer partners. You will also own the full arc of risk adjustment and clinical documentation integrity (CDI): prospective and retrospective coding programs, HCC capture and recapture accuracy, clinician education, audit readiness and defense, EHR and workflow design, vendor oversight, and the analytics that tell us whether any of it is working.\nHolding both functions in one role is deliberate. Quality and risk adjustment place overlapping demands on the same clinicians, the same visits, and the same medical record, and we want one leader accountable for making those demands coherent. This role is also accountable for accuracy in both directions — capturing conditions that are genuinely present and documented, removing those that are not, and closing care gaps because the care happened rather than because a rate needed to move.\nKey Responsibilities:\nQuality Program Ownership:\n\n Own HEDIS and Medicare Advantage Star Ratings performance for Herself Health — set annual measure targets, build the strategy to reach them, and hold accountability for the results across all clinics and payer contracts.\n Prioritize the measures most consequential for women 65+, including Breast Cancer Screening (BCS-E), Colorectal Cancer Screening (COL-E), Osteoporosis Screening in Older Women (OSW), Osteoporosis Management in Women Who Had a Fracture (OMW), Controlling High Blood Pressure (CBP), the diabetes measure set (GSD, EED, KED, SPD-E), Care for Older Adults (COA), Transitions of Care (TRC), and the medication adherence measures (MAC, MAD, MAH).\n Lead gap closure operations end to end: gap identification and prioritization, outreach campaign design, panel and scheduling strategy, standing order and protocol development, and closed-loop tracking through documented completion.\n Direct the quality team and partner with clinic leadership to embed gap closure into daily clinic workflow — pre-visit planning, care team huddles, point-of-care prompts, and post-visit follow-up — so measure performance is produced by the model of care rather than by year-end campaigns.\n Own supplemental data strategy and NCQA HEDIS submission, including chart-based and electronic clinical data submissions to payer partners, source system validation, and the accuracy and auditability of everything submitted.\n Manage the annual quality calendar: specification changes, roadmap planning, mid-year performance checkpoints, hybrid chart chase execution, and year-end close.\n Serve as the organization's primary point of contact with health plan partners on quality performance — joint operating committees, shared savings and quality incentive discussions, and payer gap file reconciliation.\n Ensure appropriate and compliant application of measure exclusions — advanced illness, frailty, palliative care, and hospice designations — so exclusions are grounded in documented clinical reality rather than applied to improve a rate.\n Partner with the patient experience and clinical operations teams on CAHPS and HOS drivers, and on the access and continuity factors that shape how patients rate their care.\n Stay current on annual NCQA specification changes and CMS Star Ratings measure and weighting updates, and translate them into concrete operational and documentation guidance for care teams.\n\nIntegration of Quality, Risk Adjustment, and Documentation:\n\n Own the coding-side accuracy of quality measure capture — correct use of CPT Category II codes, HCPCS supplemental codes, and diagnosis coding that drives numerator, denominator, and exclusion logic.\n Design annual wellness visits and comprehensive assessments so that a single encounter reliably satisfies risk adjustment documentation needs and open quality measure requirements together, minimizing duplicate clinician work.\n Deliver a single, coherent set of expectations to clinicians rather than competing asks from separate quality and coding programs.\n Analyze gap closure and measure performance alongside coding accuracy data to distinguish genuine care gaps from documentation and capture failures, and route each to the right remediation.\n\nRisk Adjustment Program Ownership:\n\n Own the end-to-end risk adjustment strategy across all Herself Health clinics and payer contracts, including prospective (pre-visit) and retrospective (post-visit) coding programs.\n Lead the organization's operating model under CMS-HCC V28 — fully phased in as of payment year 2026 — including rebuilt recapture logic, revised suspecting criteria, and updated documentation priorities reflecting V28's emphasis on clinical specificity.\n Establish and monitor RAF accuracy targets, condition recapture rates, suspect-condition close rates, and coding accuracy rates; report performance to executive leadership on a defined cadence.\n Partner with finance and actuarial colleagues to translate documentation and coding performance into accurate revenue forecasting and contract performance reporting.\n Oversee annual wellness visit and comprehensive assessment documentation workflows so the full burden of illness is captured through legitimate clinical encounters.\n\nClinical Documentation Integrity:\n\n Design, launch, and lead the CDI program: query processes, documentation standards, chart review protocols, and feedback loops between coders and clinicians.\n Develop compliant provider query practices consistent with AHIMA and ACDIS guidance, including escalation paths and query response tracking.\n Establish documentation standards supporting MEAT/TAMPER criteria, problem list hygiene, condition-status clarity, and appropriate linkage between conditions and their manifestations.\n Drive problem list stewardship across the organization so active, resolved, and historical conditions are accurately distinguished in the medical record.\n\nCoding Accuracy, Compliance, and Audit Defense:\n\n Own the internal coding audit program: sampling methodology, audit cadence, accuracy thresholds, root-cause analysis, and corrective action plans.\n Lead RADV readiness and response. With CMS expanding to annual audits of all eligible Medicare Advantage contracts and increased record volumes per contract, maintain a continuous state of audit readiness including medical record retrieval, attestation processes, and defensibility review.\n Serve as subject matter expert for payer audits, health plan chart reviews, and external coding audits; manage responses, appeals, and remediation.\n Ensure compliance with CMS risk adjustment guidance, ICD-10-CM Official Guidelines, the False Claims Act, HIPAA, and Herself Health's compliance program; partner with Compliance and Legal on policy, training, and any identified overpayment or deletion obligations.\n Establish and enforce a "delete what isn't supported" standard, with documented processes for submitting diagnosis deletions when review does not support a previously submitted code.\n\nClinician Education and Enablement:\n\n Build and deliver a clinician education curriculum covering documentation specificity, HCC concepts, common capture gaps, and query response — tailored to the conditions most prevalent in women 65+ (osteoporosis and fracture risk, dementia and cognitive decline, heart failure, chronic kidney disease, diabetes with complications, depression, autoimmune conditions, and cancer history versus active treatment status).\n Provide individualized clinician feedback using audit and performance data, delivered in a way that builds trust and skill rather than defensiveness.\n Onboard new physicians and advanced practice providers on documentation expectations and tooling.\n Serve as an accessible, credible resource for real-time clinical documentation questions.\n\nTechnology, Workflow, and Analytics:\n\n Partner with clinical informatics and IT to optimize EHR templates, point-of-care quality and coding prompts, suspecting logic, care gap registries, and documentation workflows that reduce clinician burden.\n Evaluate, select, and manage quality, coding, NLP, and risk adjustment technology vendors, along with delegated coding and outreach partners; hold them to defined accuracy and service standards.\n Build the reporting infrastructure — dashboards, scorecards, and root-cause analytics — that makes quality measure performance, care gaps, and coding accuracy visible at the organization, clinic, and clinician level.\n Reconcile submissions and monitor encounter data flow, error rates, and payer acceptance to ensure complete and accurate data submission.\n\nLeadership and Team Building:\n\n Hire, develop, and lead a combined team spanning quality program staff, certified coders, CDI specialists, and clinician educators; build a culture grounded in accuracy, curiosity, and clinical partnership.\n Establish productivity and quality standards for the team, including inter-rater reliability testing and ongoing credential maintenance.\n Build the function to scale as Herself Health grows into new markets, including scalable playbooks, training materials, and documented policies and procedures.\n Represent quality, coding, and documentation performance to the executive team, the board, and payer partners, and in cross-functional forums with population health and clinical operations.\n\nMust-have Qualifications and Skills:\n\n Bachelor's degree in health information management, nursing, healthcare administration, or a related field; equivalent experience will be considered.\n Active coding certification — CPC, CRC, CCS, CCS-P, RHIA, or RHIT. CRC (Certified Risk Adjustment Coder) strongly preferred.\n Seven or more years of progressive experience in medical coding, risk adjustment, or clinical documentation integrity, including three or more years in a leadership or program ownership role.\n Deep working knowledge of the CMS-HCC risk adjustment model, including the V24-to-V28 transition and its practical implications for documentation and capture.\n Demonstrated experience building or substantially rebuilding a risk adjustment or CDI program, not solely operating an inherited one.\n Direct experience with RADV or payer audit response, including medical record defensibility review.\n Strong command of the ICD-10-CM Official Guidelines for Coding and Reporting, Medicare Advantage risk adjustment data validation requirements, and compliant provider query practice.\n Demonstrated ownership of HEDIS and Medicare Advantage Star Ratings performance, including measure strategy, gap closure operations, supplemental data, and NCQA submission — with results you can speak to.\n Working knowledge of NCQA HEDIS technical specifications and CMS Star Ratings measure and weighting methodology.\n Proven ability to teach and influence physicians and advanced practice clinicians.\n Fluency with EHR systems and reporting tools; comfort working with data to identify patterns and prioritize action.\n\nNice-to-have Qualifications and Skills:\n\n Experience in value-based, capitated, or full-risk primary care — particularly senior-focused or Medicare Advantage populations.\n Clinical background (RN or LPN) in addition to coding credentials.\n CDI certification — CDIP, CCDS, or CCDS-O.\n Experience in a high-growth or multi-site organization where infrastructure had to be built alongside operations.\n Experience with CAHPS, HOS, or patient experience improvement work.\n Formal quality improvement training or certification (CPHQ, Lean, Six Sigma, or IHI methodology).\n Experience serving geriatric or women's health populations.\n\nCore Competencies:\n\n Integrity under pressure. Willing to say a code is not supported, including when it is financially inconvenient.\n Clinical credibility. Can hold a substantive conversation with a physician about a patient's clinical picture, not just a code set.\n Systems thinking. Sees the connection between a template field, a query workflow, a coder's productivity target, a measure rate, and an audit outcome.\n Operational follow-through. Can move a measure rate, not just report on one — comfortable owning outreach campaigns, workflow change, and the unglamorous work of closing loops.\n Teaching orientation. Makes complex regulatory material usable by busy clinicians.\n Builder's bias. Comfortable with ambiguity and with writing the first version of a process that does not yet exist.\n Mission alignment. Genuinely cares about older women being seen accurately and
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