Director, RADV Audit Operations

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most : the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Director of RADV Audit Operations is responsible for managing and overseeing the tactical and opera-tional aspects of the RADV audit process, including medical record retrieval, coding validation, and audit logistics. This role ensures compliance with CMS timelines, quality standards, and cross-department coordination for all RADV-related operational activities at Alignment.

Job 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.

Supervisory Responsibilities :

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.

Job Requirements : Experience :

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

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

Education :

Required : Bachelor's degree in a relevant field

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

Specialized Skills :

Required : 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.

Pay Range : $149,882.00 - $224,823.00

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Alignment Health is an Equal Opportunity / Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.