Director, Quality, Clinical Coding and Documentation

Director, Quality, Clinical Coding and Documentation - Job Description

Employment Type: Full-Time, Exempt

Level: Director

Location: Twin Cities Metro, MN or remote, with travel into market as needed

Reports To: Chief Medical Officer

Who We Are:

At Herself Health, we're on a mission to help women get more life out of life, together.

We're reimagining primary care for women on Medicare by delivering the kind of care they deserve: thoughtful, relationship-centered, and designed specifically for the realities of aging. We believe healthcare should never feel rushed, impersonal, or one-size-fits-all. That's why our care model gives patients more time with their care team and focuses on the health issues that matter most to women later in life—from post-menopausal care and bone health to weight management, preventive care, and mental, emotional, and social well-being.

We're building more than a better healthcare experience—we're building a team united by purpose. Every role at Herself Health contributes to creating exceptional experiences for our patients, our teammates, and the communities we serve.

Our values guide how we work every day:

Her, First – We put women at the center of every decision and every interaction.

Curious, Always Learning – We ask questions, embrace new ideas, and continuously improve.

Own It, Act – We take initiative, follow through, and hold ourselves accountable for results.

Together, Unstoppable – We achieve more through collaboration, trust, and supporting one another.

Today, Herself Health serves women 65+ in five primary care clinics dispersed across the Twin Cities metro of Minnesota. As we continue to grow, we're looking for passionate, mission-driven people who want to help shape the future of healthcare for women.

About the Director, Quality, Clinical Coding and Documentation Operations Role:

The Director, Quality, Clinical Coding and Documentation owns the two functions that determine whether Herself Health succeeds under value-based contracts: the quality of care we deliver and can demonstrate, and the accuracy of the clinical documentation and coding that describes our patients. This is a build-and-run role. You will design and lead the programs that drive HEDIS and Star Ratings performance, ensure our documentation accurately reflects the complexity of the women we serve, keep our coding compliant and defensible under audit, and make all of it workable for clinicians rather than burdensome.

You will hold accountability for quality measure performance end to end — measure strategy, gap closure operations and outreach, supplemental data and NCQA submission, and reporting to leadership and payer partners. You will also own the full arc of risk adjustment and clinical documentation integrity (CDI): prospective and retrospective coding programs, HCC capture and recapture accuracy, clinician education, audit readiness and defense, EHR and workflow design, vendor oversight, and the analytics that tell us whether any of it is working.

Holding both functions in one role is deliberate. Quality and risk adjustment place overlapping demands on the same clinicians, the same visits, and the same medical record, and we want one leader accountable for making those demands coherent. This role is also accountable for accuracy in both directions — capturing conditions that are genuinely present and documented, removing those that are not, and closing care gaps because the care happened rather than because a rate needed to move.

Key Responsibilities:

Quality Program Ownership:

Own HEDIS and Medicare Advantage Star Ratings performance for Herself Health — set annual measure targets, build the strategy to reach them, and hold accountability for the results across all clinics and payer contracts.

Prioritize the measures most consequential for women 65+, including Breast Cancer Screening (BCS-E), Colorectal Cancer Screening (COL-E), Osteoporosis Screening in Older Women (OSW), Osteoporosis Management in Women Who Had a Fracture (OMW), Controlling High Blood Pressure (CBP), the diabetes measure set (GSD, EED, KED, SPD-E), Care for Older Adults (COA), Transitions of Care (TRC), and the medication adherence measures (MAC, MAD, MAH).

Lead gap closure operations end to end: gap identification and prioritization, outreach campaign design, panel and scheduling strategy, standing order and protocol development, and closed-loop tracking through documented completion.

Direct the quality team and partner with clinic leadership to embed gap closure into daily clinic workflow — pre-visit planning, care team huddles, point-of-care prompts, and post-visit follow-up — so measure performance is produced by the model of care rather than by year-end campaigns.

Own supplemental data strategy and NCQA HEDIS submission, including chart-based and electronic clinical data submissions to payer partners, source system validation, and the accuracy and auditability of everything submitted.

Manage the annual quality calendar: specification changes, roadmap planning, mid-year performance checkpoints, hybrid chart chase execution, and year-end close.

Serve as the organization’s primary point of contact with health plan partners on quality performance — joint operating committees, shared savings and quality incentive discussions, and payer gap file reconciliation.

Ensure appropriate and compliant application of measure exclusions — advanced illness, frailty, palliative care, and hospice designations — so exclusions are grounded in documented clinical reality rather than applied to improve a rate.

Partner with the patient experience and clinical operations teams on CAHPS and HOS drivers, and on the access and continuity factors that shape how patients rate their care.

Stay current on annual NCQA specification changes and CMS Star Ratings measure and weighting updates, and translate them into concrete operational and documentation guidance for care teams.

Integration of Quality, Risk Adjustment, and Documentation:

Own the coding-side accuracy of quality measure capture — correct use of CPT Category II codes, HCPCS supplemental codes, and diagnosis coding that drives numerator, denominator, and exclusion logic.

Design annual wellness visits and comprehensive assessments so that a single encounter reliably satisfies risk adjustment documentation needs and open quality measure requirements together, minimizing duplicate clinician work.

Deliver a single, coherent set of expectations to clinicians rather than competing asks from separate quality and coding programs.

Analyze gap closure and measure performance alongside coding accuracy data to distinguish genuine care gaps from documentation and capture failures, and route each to the right remediation.

Risk Adjustment Program Ownership:

Own the end-to-end risk adjustment strategy across all Herself Health clinics and payer contracts, including prospective (pre-visit) and retrospective (post-visit) coding programs.

Lead the organization’s operating model under CMS-HCC V28 — fully phased in as of payment year 2026 — including rebuilt recapture logic, revised suspecting criteria, and updated documentation priorities reflecting V28’s emphasis on clinical specificity.

Establish and monitor RAF accuracy targets, condition recapture rates, suspect-condition close rates, and coding accuracy rates; report performance to executive leadership on a defined cadence.

Partner with finance and actuarial colleagues to translate documentation and coding performance into accurate revenue forecasting and contract performance reporting.

Oversee annual wellness visit and comprehensive assessment documentation workflows so the full burden of illness is captured through legitimate clinical encounters.

Clinical Documentation Integrity:

Design, launch, and lead the CDI program: query processes, documentation standards, chart review protocols, and feedback loops betw