Medical Coding Audit Manager

Manages the day-to-day operations of the Medical Coding Evaluation team supporting Veradigm's enterprise coding capability. The team reviews the outputs of AI agents against clinical documentation to confirm that codes are supported, billable, and accurate, and its judgments establish the clinical ground truth used to measure how our AI agents perform.

Owns the scoring guide that defines how agent output is judged, incorporating input from the reviewers who apply it. Adjudicates disagreements between reviewers, measures and reports inter-reviewer agreement, and defines the clinical metrics reported to customers, so that accuracy claims made commercially and under federal transparency requirements are defensible. Builds and develops a distributed team of certified coders, plans capacity across specialties, and extends the team's scope across coding, chart preparation, and clinical note quality as the AI roadmap expands.

ESSENTIAL FUNCTIONS / MAJOR JOB RESPONSIBILITIES

• Develops and maintains the scoring guide with clinical experts, updating it as specialties and agent behaviors expand.
• Manages daily operations for the review team, including assignments, priorities, capacity, and throughput.
• Adjudicates dual-review disputes, documenting rationale and identifying reviewer error versus guide ambiguity.
• Tracks inter-reviewer agreement, using low agreement to refine guidance rather than penalize staff.
• Runs calibration rounds across reviewers to set throughput benchmarks and validate scaling readiness.
• Reports clinical metrics, accuracy, claims inclusion, and risk impact, to leadership, product teams, and clients.
• Plans specialty coverage, starting with internal medicine and expanding as scope broadens.
• Expands scope into chart prep and note quality, establishing evaluation criteria for subjective tasks.
• Validates automated scoring through sampling and reports divergences between automated and expert review.
• Coordinates design-partner evaluations to maintain consistent review standards across teams.
• Enforces approved data access boundaries, authorized data tiers, and compliant review tools.

JOB REQUIREMENTS

• Bachelor's Degree in Health Information Management, Healthcare Administration, or equivalent technical or business experience
• 8+ years relevant work experience; 2-3 years at the Expert level or equivalent experience - Preferred
• 4 Years ICD-10-CM, CPT, and HCPCS coding across multiple specialties, with strong attention to detail and a high accuracy rate
• 2 Years coding auditing or coding quality review
• 2 Years outpatient or ambulatory coding in a multi-specialty or large group practice setting
• 1 Year developing coding guidelines, audit criteria, or annotation standards that others apply
• 1 Year reviewing output from automated or computer-assisted coding tools, or other structured annotation work
• Medicare Risk Adjustment or HCC coding experience - preferred
• 2-4 years relevant leadership experience, including leading distributed or remote teams - preferred

Certifications

• CPC, CCS, or CCS-P - AAPC or AHIMA coding certification, active -Required
• CPMA - Certified Professional Medical Auditor - Preferred
• CRC - Certified Risk Adjustment Coder - Preferred

Knowledge, Skills and Abilities

• Expert-level knowledge of medical coding, including ICD-10-CM, CPT, HCPCS Level II, modifier application, E/M documentation guidelines, and CMS claims processing rules.
• Ability to write clear, unambiguous evaluation criteria that multiple reviewers can apply to reach the same conclusion on the same record.
• Working understanding of measurement concepts relevant to human review, including inter-rater agreement, sampling, and the difference between reviewer error and ambiguous guidance.
• Ability to explain coding reasoning to engineers and product managers who have no coding background, and to translate their technical questions into coding terms.
• Sound judgment in cases where documentation is incomplete or coding guidance does not clearly apply, and the discipline to distinguish confident conclusions from uncertain ones.
• Proven ability to lead others, including where the next-level leader is not in the same location or time zone.
• Ability to work independently with minimal supervision in an environment where standards and processes are still being established.
• Working knowledge of HIPAA privacy and security requirements as they apply to handling clinical information and de-identified data.

Working Arrangements

• Standard work week or as defined by assignment requirements.
• Primarily works in a standard office environment or remotely.
• Requires periodic overlap with United States time zones to collaborate with Applied Intelligence, product, and engineering teams.

Travel

• Up to 10% travel may be required.

Benefits

Veradigm believes in empowering our associates with the tools and flexibility to bring the best version of themselves to work. Through our generous benefits package with an emphasis on work/life balance, we give our employees the opportunity to allow their careers to flourish. 

• Quarterly Company-Wide Recharge Days

• Flexible Work Environment (Hybrid)

• Peer-based incentive “Cheer” awards

• Tuition Reimbursement Program

To know more about the benefits and culture at Veradigm, please visit the links mentioned below: -

https://veradigm.com/about-veradigm/careers/benefits/ 

https://veradigm.com/about-veradigm/careers/culture/ 

#LI-SL1 #LI-Hybrid

Veradigm is proud to be an equal opportunity workplace dedicated to pursuing and hiring a diverse and inclusive workforce.

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