Description

The Director of Coding Compliance & Education plays a critical leadership role in ensuring that our clinical DRG validation services meet all regulatory, coding, and documentation requirements. This position supports a physician-led review team working with acute care and long-term acute care hospitals to validate Diagnosis-Related Groups (DRGs) prior to billing. The Director is responsible for maintaining coding compliance standards, leading internal audits, and delivering training and education that empower our clinicians to provide accurate and defensible reviews.

Responsibilities:

Compliance Oversight: 

• Maintain and update the company’s coding compliance policies in alignment with CMS regulations, OIG guidance, HIPAA, and industry standards.
• Serve as the company’s primary subjectmatter expert on MSDRG and APRDRG validation, ICD10CM/PCS, CPT/HCPCS, Quality Measures, and related reimbursement methodologies.
• Monitor regulatory changes impacting DRG validation and communicate updates internally.
• Lead/conduct internal and external quality reviews; design and monitor correctiveaction plans.

Education & Training:

• Develop and deliver onboarding training and continuing education programs for physician reviewers on ICD-10-CM/PCS, MSDRG and APRDRG assignments, and documentation best practices.
• Create, deliver and maintain a scalable learning ecosystem (live webinars, asynchronous elearning, job aids) that keeps our physician reviewers and client ‘s current on clinical documentation requirements.
• Oversee the development of curriculum for onboarding, annual competencies, and specialized refreshers.

Encoder & Technology Oversight:

• Maintain oversight of encoder tools and associated reference platforms to ensure they are current, fully functional, and aligned with regulatory changes.
• Coordinate with technology vendors or internal IT to implement updates or enhancements
• Provide training and support to end users to ensure optimal use and understanding of encoder platforms.

Quality Improvement:

• Define and track key performance indicators (e.g., hiring and training throughput, recommendation rate, acceptance rate, case weight change, accuracy, turnaround time, denial overturn rate, quality review findings) to identify trends and areas for improvement.
• Working with physician reviewers, develop action plans and performance improvement plans to address lagging key performance indicators and trends.

Cross-Functional Collaboration:

• Serve as a subject matter expert to the product and development teams by providing insight into coding, DRG validation, encoder logic, and regulatory requirements.
• Assist in aligning product features with current compliance standards and user needs.

Client & Regulatory Engagement:

• Assist in client education sessions related to documentation, coding trends, and compliance expectations.
• Represent the organization at industry conferences (AHIMA, ACDIS, HFMA) and maintain relationships with governing bodies and professional associations.

Team Leadership:

• Lead and mentor a highperforming team of physician reviewers and physician educators.
• Develop annual budgets, staffing plans, and professionaldevelopment road maps.

Requirements

Education: Bachelor's degree in health information management, Nursing, or related field; master's in health administration (MHA), MBA, or equivalent preferred.

Credentials: RHIA, RHIT or CCS required; CDIP strongly preferred.

Experience:
Minimum of 7 years’ progressive leadership in hospital coding, clinical documentation, DRG validation, or revenuecycle compliance.
Demonstrated success building or scaling enterprise education programs.
Experience with industry leading encoder software products and reference applications.
Proven track record interacting with Csuite leaders and medical staff

Technical: Deep knowledge of ICD10CM/PCS, MSDRG and APRDRG logic, Quality Measures, clinical documentation standards, and audit analytics platforms; proficiency with EMR, encoder and CAC tools.

Communication: Excellent written, verbal, and presentation skills; able to clearly convey complex coding/compliance topics to clinical and non-clinical audiences, and a passion for mentorship.

Preferred Attributes

Experience in a physicianled vendor or outsourced DRG review environment.
Working knowledge of payorspecific denial trends and appeals strategies.
Familiarity with AIenabled coding and documentation technologies.