Senior Manager, Clinical and Coding

Health Business Solutions (HBiz) is seeking an experienced and strategic Senior Manager to lead and oversee clinical and coding operations across government and commercial payers, including post-pay audit. This role manages end-to-end clinical and coding audit activities, ensuring regulatory compliance, driving audit accuracy, and optimizing financial and operational outcomes for clients.

Responsibilities

• Lead and oversee clinical and coding audits, including government and commercial payer audits (e.g., RAC, MAC, CERT, PERM, TPE, and commercial payer reviews).
• Direct audit intake, medical record review, clinical validation, coding accuracy assessments, quality assurance, and final deliverables.
• Ensure audits are conducted in accordance with CMS regulations, official coding guidelines, payer policies, and internal compliance standards.
• Provide subject-matter expertise in ICD-10-CM/PCS, CPT, HCPCS, MS-DRG/APR-DRG validation, and clinical documentation integrity.
• Review complex, high-risk audit findings and support defensible, well-documented outcomes.
• Partner with clinical, coding, and appeals teams to support rebuttals, appeals, and education initiatives.
• Manage, mentor, and develop a team of clinical auditors, coding auditors, and audit leads, including onshore and offshore resources.
• Assign workloads, monitor productivity and quality metrics, and ensure timely completion of audits.
• Foster a culture of collaboration, accountability, and continuous improvement.
• Track audit outcomes, denial trends, and financial impact across clients and payers.
• Develop and present audit performance reports, dashboards, and executive-level summaries.
• Identify systemic risks and recommend proactive strategies to reduce future audit exposure and improve compliance.
• Serve as a senior point of contact for clients, providing guidance on audit strategy, findings, and risk mitigation.
• Collaborate with internal leadership, operations, and clinical teams to align audit activities with organizational goals.
• Support business development efforts by contributing audit expertise to proposals, client discussions, and service enhancements.
• Lead complex DRG denial reviews and appeals, conducting comprehensive clinical and coding validation to identify inaccurate payer determinations and maximize reimbursement recovery for inpatient claims.
• Establish and maintain standardized denial management workflows, audit programs, and escalation processes to improve appeal success rates and reduce future denials.
• Develop and monitor DRG denial metrics, recovery rates, and payer performance dashboards, presenting findings and strategic recommendations to executive leadership.
• Provide expert oversight of clinical documentation, coding practices, and regulatory requirements affecting DRG assignment and reimbursement.

Requirements

• Bachelor’s degree in Health Information Management, Nursing, Healthcare Administration, or a related field.
• 7+ years of progressive experience in healthcare auditing, with significant focus on clinical and coding post-pay audits.
• 1+ years of experience in people leadership with responsibility for training, coaching, and providing performance feedback.
• Demonstrated leadership experience managing audit teams and complex audit programs.
• Strong working knowledge of CMS regulations, official coding guidelines, and payer audit processes.
• Professional credentials such as RHIA, RHIT, CCS, CCS-P, CPC, CPMA, RN, or equivalent.

Preferred Qualifications

• Experience with audit tracking systems, EHRs, and performance dashboards.
• Prior experience supporting audit appeals and rebuttals.

Skills

• Excellent analytical, communication, and presentation skills.
• Ability to manage multiple projects and deadlines in a remote environment.
• High attention to detail with strong problem-solving and decision-making capabilities.
• Collaborative leadership style with a client-focused mindset.