Director of Compliance and Revenue Integrity

Essen Medical Associates•New York, NY

2d•$100,000 - $135,000

About The Position

The Director of Compliance and Revenue Integrity is accountable for day-to-day compliance with regulatory and program requirements across Essen’s Nursing Home and Intention Health Care in-home house calls operations. The Director leads identification, correction, and closure of compliance issues, including developing and completing Corrective Action Plans (CAPs), and ensures billing, documentation, and coding are accurate and defensible. The role monitors, audits, investigates, escalates, and advises independently of operational management, with authority to bring concerns directly to the Board. It owns operational compliance, survey and audit readiness, remediation, revenue integrity, independent monitoring and investigations, and maintenance of the compliance program. The Director advises management and the Board on legal and regulatory risks 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/Requirements for long-term care facilities; and the False Claims Act, 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 skills.
Strong investigative, analytical, and documentation skills.
Clear written and verbal communication skills.
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, including CMS requirements, state regulations, Medicare and Medicaid billing rules, and Intention Health 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 of 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, administration, and Intention Health Care program staff to correct issues promptly 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 authority to access 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 matters involving senior leadership.
Provide the Board regular 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, documentation of program effectiveness, 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.