Manager, Coding Quality and Compliance Auditing

Role Description

Oak Street Health®, a part of CVS Health, helps older adults stay healthier and live fuller lives through our 230 centers across 27 states. Our value-based care model helps us consistently deliver better patient experiences and outcomes.

Job Overview

Oak Street Health seeks an experienced Manager of Coding Quality and Compliance. This role requires deep medical coding expertise, experience contributing to Epic workflow design, and confidence working across teams (Rev Cycle, Coding, Clinical Documentation, executive leadership).

Technical Chart Auditing

• Conducts daily quality checks and secondary reviews among coding audit staff to verify standard industry coding guide compliance (ICD-10-CM, CPT, HCPCS)
• E/M code selection accuracy
• Congnitive Modifier usage (e.g., Modifier 25)

Epic Work Queue Rules Maintenance

• Manages external audit execution and internal CMS Risk Adjustment Data Validation (RADV) readiness
• Conducts routine mock RADV audits to validate HCC chronic condition support

Query Compliance Oversight

• Audits and enforces compliant Provider Query practices across coding and CDA staff
• Ensures adherence to AHIMA/ACDIS standards to eliminate leading queries and maintain non-biased documentation integrity

Epic Rule Engine Optimization

• Partners directly with IT analysts to translate high-risk OIG selection parameters (e.g., active stroke without hospital stay, or vascular codes without anticoagulants) and other Compliance priorities into native Epic tools

Deletion Log Maintenance & Overpayment Tracking

• Mandates and tracks the technical Deletion & Reconciliation workflow
• Enforces strict adherence to the 60-day federal overpayment refund standard

Payer Data Ingestion Auditing

• Audits incoming payer supplemental data files, gap-closure feeds, and automated clinical inference outputs
• To verify that suggested chronic conditions meet CMS coding standards before inclusion in risk-score submissions

Required Qualifications

• Post secondary /high school education or specialized training, i.e., technical/vocational programs
• 5 to 7 years relevant experience
• 2 to 4 years of risk adjusted coding experience
• Certified Coding Specialist (CCS), Certified Coding Associate (CCA) or Certified Professional Coder (CPC)
• Credential of at least 3 years by AHIMA or AAPC required. Dual AAPC certification a plus. Credential must be current, in good standing, and maintained during employment.
• ID-10 Coding certification
• ID-9-CM coding experience
• ID-10-CM coding experience
• Proven coding competency
• Prior medical chart auditing/quality experience
• Advanced knowledge of medical terminology, abbreviations, anatomy and physiology, major disease processes and pharmacology

Preferred Qualifications

• RCC
• RHIT or RHIA

Benefits

Mission-focused career impacting change and measurably improving health outcomes for Medicare patients

Paid vacation, sick time, and investment/retirement 401K match options

Health insurance, vision, and dental benefits

Opportunities for leadership development and continuing education stipends

New centers and flexible work environments

Opportunities for high levels of responsibility and rapid advancement

About the Role

Subject matter expert, problem solver, and relationship builder with a talent for creative problem solving & execution

Excellent at communicating audit & compliance concepts to colleagues in other functions

Responsibilities

Internal Auditing Controls

Conducts daily quality checks and secondary reviews among coding audit staff to verify standard industry coding guide compliance (ICD-10-CM, CPT, HCPCS), E/M code selection accuracy, and compliant Modifier usage (e.g., Modifier 25).

VBC & RADV Audit Operations

Manages external audit execution and internal CMS Risk Adjustment Data Validation (RADV) readiness, conducting routine mock RADV audits to validate HCC chronic condition support.

Query Compliance Oversight

Audits and enforces compliant Provider Query practices across coding and CDA staff, ensuring adherence to AHIMA/ACDIS standards to eliminate leading queries and maintain non-biased documentation integrity.

Epic Rule Engine Optimization

Partners directly with IT analysts to translate high-risk OIG selection parameters (e.g., active stroke without hospital stay, or vascular codes without anticoagulants) and other Compliance priorities into native Epic tools.

Deletion Log Maintenance & Overpayment Tracking

Mandates and tracks the technical Deletion & Reconciliation workflow, enforcing strict adherence to the 60-day federal overpayment refund standard.

Payer Data Ingestion Auditing

Audits incoming payer supplemental data files, gap-closure feeds, and automated clinical inference outputs to verify that suggested chronic conditions meet CMS coding standards before inclusion in risk-score submissions.

Qualifications

• Post secondary /high school education or specialized training, i.e., technical/vocational programs
• 5 to 7 years relevant experience
• 2 to 4 years of risk adjusted coding experience
• Certified Coding Specialist (CCS), Certified Coding Associate (CCA) or Certified Professional Coder (CPC)
• Credential of at least 3 years by AHIMA or AAPC required. Dual AAPC certification a plus. Credential must be current, in good standing, and maintained during employment.
• ID-10 Coding certification
• ID-9-CM coding experience
• ID-10-CM coding experience
• Proven coding competency
• Prior medical chart auditing/quality experience
• Advanced knowledge of medical terminology, abbreviations, anatomy and physiology, major disease processes and pharmacology