Director of Compliance and Revenue Integrity

• →Own day-to-day compliance with applicable program rules, including CMS requirements, state regulations, Medicare/Medicaid billing rules, and IHC program requirements and reporting obligations.
• →Translate regulatory and program requirements into practical policies, workflows, and staff guidance for operations.
• →Serve as the point of accountability for survey, audit, and program-review readiness.

• →Lead root-cause analysis for identified issues, whether from surveys, audits, hotline reports, payer or government reviews, or internal monitoring.
• →Develop, implement, and track CAPs through completion, including evidence of correction and sustained compliance.
• →Coordinate with operational leaders (clinical, billing, administration, IHC program staff) to correct issues promptly and prevent recurrence.
• →Manage overpayment identification, quantification, and refund/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 such as resident assessment and case-mix accuracy, therapy and skilled-need documentation, E/M and house-call visit coding, medical necessity, and eligibility/attestation requirements.
• →Analyze billing and utilization data to detect outliers, trends, and risk, and partner with Finance/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 all reports are triaged, investigated, and documented.
• →Perform exclusion screening and oversee compliance of vendors and contractors.

• →Escalate significant issues to the CAO and, when appropriate, directly to the Board, including matters involving senior leadership.
• →Provide the Board with 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, code of conduct, documentation of program effectiveness, and annual program assessment.

• →Serve as the resource for compliance questions on 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.

• Bachelor’s degree in healthcare administration, business, nursing, law, or related field (Master’s, JD, or RN preferred).
• 8+ years of healthcare compliance, revenue integrity, or audit experience, with 3+ years in a leadership role.
• Direct experience in skilled nursing/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 CAPs to closure.
• Experience presenting to boards or senior executive teams.

• 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 New York regulatory environment (DOH, OMIG).
• Data analytics skills for claims and utilization review.

• 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

Essen Health care is proud to be an equal opportunity employer, and we seek candidates who desire to work in and serve an ethnically diverse population.