Director of Compliance and Revenue Integrity

Essen Medical Associates•Bronx, NY

About The Position

The Director of Compliance and Revenue Integrity is accountable for day-to-day compliance across Essen Health Care’s Nursing Home and In-Home Care house calls operations within Intention Health Care. The role leads identification, correction, and closure of compliance issues, including the development and completion of Corrective Action Plans, and ensures that billing, documentation, and coding are accurate and defensible. The Director monitors, audits, investigates, escalates, and advises independently from operational management, and may bring concerns directly to the Board. The Director owns operational compliance with program rules, CMS requirements, state regulations, Medicare and Medicaid billing rules, and In-Home Care program requirements. The role translates requirements into practical policies and workflows, prepares for surveys and audits, directs remediation, and oversees revenue integrity. It also designs and executes risk-based monitoring and audits, investigates suspected noncompliance, fraud, waste, or abuse, manages hotline reports and exclusion screening, and provides independent reporting and advice to the CAO and Board. The Director maintains and improves the compliance program in line with OIG guidance and applicable state requirements, including New York OMIG compliance program elements. The role develops and delivers training, maintains policies and program documentation, advises on new services and business arrangements, and partners with legal counsel on regulatory inquiries and government communications.

Requirements

Bachelor’s degree in healthcare administration, business, nursing, law, or a related field.
At least 8 years of healthcare compliance, revenue integrity, or audit experience.
At least 3 years of experience in a leadership role.
Direct experience in skilled nursing or long-term care and/or home-based or house calls programs.
Working knowledge of Medicare and Medicaid billing and coding, CMS Conditions or Requirements for long-term care facilities, the False Claims Act, the Anti-Kickback Statute, and Stark Law.
Demonstrated experience leading investigations, audits, and Corrective Action Plans to closure.
Experience presenting to boards or senior executive teams.
Integrity, professional courage, and willingness to deliver difficult messages to senior leaders and the Board.
Practical, operations-minded problem solving.
Strong investigative, analytical, and documentation skills.
Clear written and verbal communication.
Ability to build trust with clinical and operational teams while maintaining independence.

Nice To Haves

Master’s degree, JD, or RN.
CHC, CCEP, CPC, CHPC, or similar certification.
Familiarity with value-based or total-cost-of-care programs, including Independence at Home or similar house calls models.
Experience in the New York regulatory environment, including DOH and OMIG.
Data analytics skills for claims and utilization review.

Responsibilities

Own day-to-day compliance with applicable program rules, CMS requirements, state regulations, Medicare and Medicaid billing rules, and In-Home Care program requirements and reporting obligations.
Translate regulatory and program requirements into practical policies, workflows, and staff guidance.
Serve as the point of accountability for survey, audit, and program-review readiness.
Lead root-cause analysis for issues identified through surveys, audits, hotline reports, payer or government reviews, and internal monitoring.
Develop, implement, and track Corrective Action Plans through completion, including evidence of correction and sustained compliance.
Coordinate with clinical, billing, administrative, and In-Home Care program leaders to correct issues and prevent recurrence.
Manage overpayment identification, quantification, and refund or self-disclosure processes in coordination with legal counsel.
Ensure charge capture, coding, documentation, and claims submission are accurate, supported, and compliant.
Oversee review of high-risk areas, including resident assessment and case-mix accuracy, therapy and skilled-need documentation, E/M and house-call visit coding, medical necessity, and eligibility and attestation requirements.
Analyze billing and utilization data to detect outliers, trends, and risks, and partner with Finance and Revenue Cycle on corrective measures.
Design and execute a risk-based annual compliance work plan and audit schedule.
Conduct or direct audits and investigations of suspected noncompliance, fraud, waste, or abuse, with access to records, systems, and personnel.
Manage the compliance hotline and non-retaliation policy; ensure reports are triaged, investigated, and documented.
Perform exclusion screening and oversee vendor and contractor compliance.
Escalate significant issues to the CAO and, when appropriate, directly to the Board, including issues involving senior leadership.
Provide regular Board reports on audit results, investigations, CAP status, overpayments, regulatory developments, and program effectiveness.
Advise management and the Board independently on legal and regulatory risk, including recommending actions management may not favor.
Maintain and continuously improve the compliance program in line with OIG guidance and applicable state requirements, including NY OMIG compliance program elements.
Develop and deliver compliance training and education for staff, leaders, and the Board.
Maintain policies, the code of conduct, program-effectiveness documentation, and the annual program assessment.
Advise on compliance questions involving new service lines, contracts, referral relationships, marketing, and operational changes, including Anti-Kickback and Stark considerations.
Partner with legal counsel on regulatory inquiries, subpoenas, and government communications.