Quality Coding Program Manager

Gold Coast Health Plan

. Develop and maintain a Quality Coding work-plan and convene committees and workgroups to drive and oversee risk adjustment work .

Posted 9/21/2026full-timeRemote • California • United StatesMid-LevelSenior💰 $100,000 - $150,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in risk adjustment coding, compliance with CMS regulations, and effective program management within healthcare settings. Proficient in data analysis, reporting, and provider education to enhance clinical documentation and performance outcomes.

Highest-signal resume keywords

Certified Professional Coder (CPC)Certified Risk Adjustment Coder (CRC)Risk Adjustment MethodologiesCMS-HCC KnowledgeMedicare Advantage Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical CodingHCC CodingCoding AuditsData ManagementICD-10-CMCPTHCPCSPerformance Data AnalysisQuality Coding InitiativesRegulatory Compliance

Soft Skills

Analytical SkillsProblem-SolvingCommunication SkillsOrganizational SkillsTime Management

Tools & Technologies

Electronic Medical Record (EMR/EHR) SystemsMicrosoft Office Suite

Certifications & Qualifications

Certified Coding Specialist (CCS)Valid Driver's LicenseAuto Insurance

Industry Keywords

Risk AdjustmentCMS RequirementsMedicare AdvantageACA/Exchange RequirementsRADV Processes

About the role

Key responsibilities & impact

Develop and maintain a Quality Coding work-plan and convene committees and workgroups to drive and oversee risk adjustment work
Implement and oversee quality coding initiatives and projects
Partner with internal teams and external vendors to monitor program and vendor performance and facilitate improvement activities
Ensure complete, accurate, timely, and compliant reporting of risk adjustment data in accordance with CMS requirements
Coordinate, develop, and analyze key indicators, performance data, and reporting tools for risk adjustment operations and quality coding programs
Define, design, implement, and maintain data files and data extracts for reporting needs
Maintain knowledge of applicable laws, regulations, and CMS guidance for risk adjustment, Medicare Advantage, and ACA/Exchange requirements
Deliver provider and staff education to facilitate clinical documentation improvement and improve performance and outcomes
Review and audit medical record documentation to validate diagnoses and ensure CMS Risk Adjustment compliance
Support CMS RADV audit readiness, including chart validation, mock audits, record retrieval, documentation reconciliation, and regulatory submissions
Identify trends, compliance risks, and audit findings through analysis of coding, documentation, provider, and vendor performance data
Partner with Finance to forecast risk adjustments and track coding-quality impact
Potential travel for auditing purposes
Perform other duties as assigned

Requirements

What you’ll need

California residency required; this position is open to California residents only
Bachelor’s degree in Health Information Management, Healthcare administration, Public Health or a related field
Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), or Certified Coding Specialist (CCS)
3–5 years of experience in medical coding, risk adjustment, HCC coding, coding audits, and provider education
Strong knowledge of CMS-HCC, HHS-HCC, RADV processes, ICD-10-CM, CPT, HCPCS, risk adjustment methodologies, and CMS rules for Medicare Advantage health plans
Experience developing and managing healthcare-related programs from ideation through execution in a highly matrixed environment
Experience in a Medicare Advantage health plan or managed care setting
Experience navigating electronic medical record (EMR/EHR) systems
Analytical, data management, problem-solving, critical-thinking, strategic-thinking, organization, time-management, prioritization, communication, and presentation skills
Ability to manage multiple projects and adapt to changing priorities and business needs
Ability to present complex information in a simplified, easy-to-understand manner
Technical aptitude to learn new data management and analysis tools or methodologies quickly
Proficiency with Microsoft Office Suite
Valid and current Driver's License, Auto Insurance, and professional licensure(s)