Compliance Lead – RCM & Clinical Documentation (Clinical Background Required)
About The Position
The Operational Compliance Lead is an embedded, frontline role managing day-to-day RCM and clinical operations compliance within Essen Health Care and its Nursing Home division. This is a hands-on operational position – distinct from the corporate compliance function – focused on identifying, correcting, and monitoring coding and billing accuracy before issues escalate to external review. Drawing on a clinical background (IMG preferred) and coding expertise, this Lead works directly with administrative and clinical operations leaders to drive documentation integrity, prevent CMS or state audit exposure, and ensure the organization is always audit-ready.
Requirements
- Bachelor’s Degree in Healthcare Administration, Nursing, Health Information Management, Public Health, or related field.
- Clinical background required; International Medical Graduate (IMG) or foreign medical degree highly valued.
- Active coding certification: CPC, CRC, CCS, or equivalent.
- Minimum 3 years of operational compliance, coding, clinical chart review, or RCM experience; demonstrated ability to develop and close out CAPs.
- Strong knowledge of ICD-10-CM, CPT, HCPCS, HCC/Risk Adjustment, Medicare/Medicaid regulations, and HIPAA.
- Demonstrated ability to present audit findings and CAPs to senior leadership; comfortable owning follow-through to resolution.
Nice To Haves
- Master’s Degree (MHA, MPH, MBA with healthcare focus, MSN, or equivalent) – strongly preferred given the organizational complexity and cross-functional leadership demands of this role.
- Project management experience or certification (PMP, CAPM, or equivalent).
- Experience in Medicare Advantage, value-based care, and/or Clinical Documentation Improvement (CDI).
- Experience with eClinicalWorks ( eCW ) or similar EMR systems.
- Prior experience providing provider education and compliance training.
Responsibilities
- Conduct routine and targeted clinical chart reviews and RCM audits assessing coding accuracy, billing integrity, and documentation completeness across CMS and state-billed services.
- Proactively monitor for compliance risk patterns; generate ongoing trend reports to flag issues before they escalate to external review.
- Identify coding discrepancies and billing vulnerabilities with focus on ICD-10-CM, CPT, E&M level selection, and Medical Decision Making (MDM) accuracy.
- Develop, own, and drive Corrective Action Plans (CAPs) to confirmed completion, including re-audit to validate sustained improvement.
- Apply clinical knowledge to review documentation with a clinician’s lens – ensuring diagnoses, MDM, and services support the codes being billed.
- Work directly with admin and clinical operations leaders on ICD-10-CM, CPT, E&M, HCPCS, and HCC/risk adjustment coding accuracy.
- Serve as the operational compliance liaison to RCM – bridging clinical documentation, coding, and billing to ensure alignment and defensibility.
- Deliver targeted, clinically grounded education to physicians, NPs, PAs, and staff on documentation best practices and coding compliance.
- Develop training content on coding standards and payer-specific regulatory requirements as guidelines evolve.
- Produce executive-ready compliance trend reports and audit summaries that inform leadership decisions and prioritize risk.
- Present CAPs to clinical and administrative leadership with clear timelines, owners, and success metrics – then own follow-through to resolution.
- Act as the first line of resolution before issues surface at the corporate compliance level; maintain continuous audit readiness.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
