Director - Quality (Medical Coding)

Position: Director - Quality_Medical Coding

Reporting To: Vice President - Medical Coding (Quality )

Department: Medical Coding – Quality & Compliance

Profile Description

This role is responsible for defining and driving the quality strategy across one or more medical coding portfolios while ensuring coding accuracy, regulatory compliance, client satisfaction, and continuous process improvement. The Director – Quality will lead enterprise quality initiatives, strengthen audit governance, partner with Operations and Training teams, and leverage analytics to improve coding quality, reduce denials, and enhance client outcomes. The role is also responsible for ensuring compliance with industry standards, payer guidelines, and organizational quality frameworks.

Key Responsibilities

Process

• Own the Quality Management System (QMS) across assigned coding portfolios and ensure consistent execution of quality processes.
• Establish and maintain coding quality standards aligned with ICD-10-CM, CPT, HCPCS, payer policies, CMS guidelines, NCCI edits, and specialty-specific coding requirements.
• Drive achievement of internal and client-defined quality SLAs across all accounts.
• Develop audit methodologies including concurrent, retrospective, prospective, focused, and validation audits.
• Ensure calibration across Quality, Operations, Training, and Client teams through standardized audit guidelines.
• Lead root cause analysis (RCA) for quality defects and implement effective corrective and preventive actions (CAPA).
• Monitor coding trends, denial trends, payer edits, and regulatory updates to proactively mitigate quality risks.
• Drive continuous process improvement initiatives through Lean, Six Sigma, and automation opportunities.
• Standardize quality scorecards, audit tools, and governance dashboards across portfolios.
• Ensure readiness for client audits, internal audits, compliance reviews, and external accreditation requirements.
• Establish governance around coding policy changes and ensure timely implementation across operations.

People

• Build and lead a high-performing Quality organization across multiple coding specialties.
• Coach and mentor Quality Managers and Leads to improve audit effectiveness and leadership capabilities.
• Develop competency frameworks for auditors and quality professionals.
• Partner with Operations and Learning teams to identify knowledge gaps and implement targeted training interventions.
• Drive certification programs (AAPC/AHIMA), continuing education, and ongoing competency assessments.
• Promote a culture of quality ownership across Operations rather than quality inspection.
• Drive employee engagement, succession planning, talent retention, and career development within the Quality function.
• Conduct regular calibration sessions to ensure inter-auditor reliability and consistency.
• Foster innovation by encouraging adoption of AI-assisted quality monitoring and analytics.

Client

• Serve as the Quality leader during client governance meetings including Weekly Business Reviews (WBRs), Monthly Business Reviews (MBRs), and Quarterly Business Reviews (QBRs).
• Present quality performance, audit findings, denial trends, and improvement initiatives to clients.
• Build trusted client relationships through proactive communication and consultative quality leadership.
• Partner with client coding compliance teams to resolve coding interpretation differences.
• Support client onboarding, transitions, and implementation activities by establishing quality governance.
• Lead provider education initiatives arising from coding audit findings when required.
• Ensure client quality KPIs, contractual obligations, and compliance expectations are consistently achieved.

Financial

• Improve client ROI by reducing coding defects, rework, denials, and revenue leakage.
• Partner with Operations leadership to improve first-pass quality and operational efficiency.
• Support account profitability by minimizing quality-related cost of poor quality (COPQ).
• Measure and report financial impact of quality improvement initiatives.
• Participate in business reviews and support strategic growth opportunities through quality excellence.
• Drive automation initiatives that improve audit efficiency and reduce manual effort.

Governance & Compliance

• Ensure compliance with HIPAA, CMS regulations, payer-specific guidelines, OIG recommendations, and organizational policies.
• Monitor coding compliance risks and implement mitigation strategies.
• Lead internal compliance audits and support external regulatory audits.
• Maintain documentation supporting quality governance and audit readiness.

Analytics & Continuous Improvement

• Develop executive dashboards highlighting quality trends, DPU, accuracy, denials, auditor agreement, productivity, and compliance metrics.
• Perform advanced trend analysis using audit data to identify systemic process improvements.
• Utilize statistical quality control techniques and predictive analytics to improve coding performance.
• Lead enterprise quality transformation initiatives leveraging AI and automation.

Qualifications

• Graduate in any discipline is mandatory.
• BPT, MPT, B.Sc Nursing, M.Sc Nursing, B.Pharm, M.Pharm, BOT, or Life Sciences preferred.
• AHIMA or AAPC certification (CPC, CCS, CCS-P, CIC, CRC or equivalent) is mandatory.
• Lean Six Sigma Green Belt or Black Belt preferred.
• MBA or Master's degree in Healthcare Administration or Quality Management will be an added advantage.
• MBBS, BDS, BAMS, BHMS, or other healthcare professional qualifications would be an added advantage.

Role Prerequisites

• 14+ years of experience in Medical Coding with significant leadership experience in Coding Quality and Compliance.
• Minimum 5 years of managing enterprise quality programs across multiple specialties and clients.
• Extensive experience in coding audits, coding compliance, provider education, and denial prevention.
• Strong understanding of US healthcare regulations, payer policies, CMS guidelines, and coding compliance.
• Experience in leading quality transformation initiatives across large teams (300+ FTE preferred).
• Demonstrated experience working with executive leadership and external clients.
• Experience in AI-enabled quality assurance, analytics, or automation initiatives is preferred.

Functional Competencies

• Expert knowledge of ICD-10-CM, CPT, HCPCS, CMS Guidelines, and NCCI edits.
• Expertise across multiple coding specialties.
• Advanced coding audit methodology and compliance knowledge.
• Strong understanding of revenue cycle management and denial prevention.
• Root Cause Analysis (RCA) and Corrective & Preventive Action (CAPA).
• Statistical quality analysis and performance analytics.
• Governance reporting and executive dashboard preparation.
• Lean Six Sigma process improvement methodologies.
• Client relationship and stakeholder management.
• Strong presentation and communication skills.
• Advanced Microsoft Excel, Power BI, and Microsoft Office/G-Suite proficiency.
• Knowledge of AI-assisted coding validation and quality monitoring tools is preferred.

Behavioral Competencies

• Accountability
• Customer Service Orientation
• Strategic Thinking
• Developing Others
• Coaching and Mentoring
• Collaboration
• Analytical Thinking
• Decision Making
• Continuous Improvement Mindset

Key Success Metrics (KPIs)

• Coding Quality Accuracy (%)
• Defect Per Unit (DPU)
• First Pass Yield (FPY)
• Coding-related Denial Rate
• Audit Completion SLA
• Auditor Agreement / Calibration Score
• Client CSAT / Quality Satisfaction Score
• Regulatory Compliance Score
• Cost of Poor Quality (COPQ)
• Training Effectiveness Score
• Quality Improvement Project Savings