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Alignment Health · 3 weeks ago

Director, RADV Audit Operations

Orange, CA

Full-time

Onsite

Lead/Staff, Director/Executive

$150K/yr - $225K/yr

5+ years exp

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most. The Director of RADV Audit Operations is responsible for managing and overseeing the tactical and operational aspects of the RADV audit process, ensuring compliance with CMS timelines and quality standards while collaborating with various departments.

Health CareHospitalMedicalMedical DeviceWellness

Responsibilities

Process management: Leading all phases of the audit process, including data sample validation, medical record retrieval, coding abstraction, quality assurance auditing and submission to CMS

Strategy and planning: Responsible for developing and implementing strategies to improve overall coding accuracy and documentation integrity, which mitigates future audit risk

Cross-functional collaboration: Working closely with other departments—such as IT, Risk Adjustment Operations, Provider Relations, and Compliance—to ensure accurate data submission and a smooth audit process

Oversee medical record retrieval processes, ensuring HIPAA compliance and timely submissions

Manage teams of auditors, coders, and project managers to execute end-to-end CMS RADV workflows

Coordinate with vendors and internal partners for coding reviews and documentation validation

Ensure the accuracy and completeness of HCC submissions during RADV cycles

Track progress and performance metrics; escalate risks to leadership as needed

Develop and maintain standard operating procedures (SOPs & P&Ps) for audit workflows

Monitors coder and physician audit results to maintain quality of information. Maintains current information on governmental regulation changes and updates affecting coding, staffing and reimbursement

Perform management responsibilities including but not limited to involvement in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct, and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority

Qualification

CMS-HCC Risk AdjustmentICD-10 coding guidelinesRADV processMedicare regulationsLeadershipProject managementQuality assuranceData validationPolicy developmentCommunicationTeam management

Required

5+ years of experience in risk adjustment, Medicare Advantage operations, and managing CMS or other regulatory audits

Bachelor's degree in a relevant field

Deep knowledge of the CMS-HCC Risk Adjustment model, ICD-10 coding guidelines, and the end-to-end RADV process is essential

Familiarity with Medicare regulations and compliance requirements is also critical

Strong leadership, communication, and project management skills are required to oversee complex, time-sensitive audits

Preferred

3+ years of experience in a leadership role and health plan medical coding processes and procedures

Professional certifications such as Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC) or Certified Coding Specialist (CCS) are highly desirable