Description:

Job Summary

The Head of Compliance will lead the design, implementation, and oversight of the organizations Revenue Cycle Management (RCM) and healthcare compliance programs. This role ensures adherence to federal, state, and payer-specific regulations, including Medicare, Medicaid, HIPAA, and industry-recognized compliance standards. The position requires strong expertise in policy development, risk mitigation, auditing, regulatory communication, and enterprise-wide compliance governance.

Key Responsibilities

1. Compliance Program Leadership

- Develop, implement, and manage the organizations end-to-end revenue cycle compliance framework.

- Establish, update, and standardize policies and procedures governing patient billing, coding accuracy, documentation integrity, and claims management.

- Drive continuous improvement initiatives to enhance compliance maturity across the RCM ecosystem.

2. Policy & Procedure Development

- Create, maintain, and enforce enterprise-wide compliance policies, SOPs, and guidelines.

- Ensure documentation aligns with regulatory requirements, payer-specific rules, and evolving healthcare standards.

- Oversee development of centralized manuals covering HIPAA controls, security procedures, and billing/coding best practices.

3. Risk Assessment & Mitigation

- Conduct periodic risk assessments across revenue cycle functions including patient intake, charge capture, coding, claim submission, denials, and reimbursement.

- Identify vulnerabilities and implement proactive measures to prevent compliance breaches.

- Partner with operational leaders to strengthen internal controls and embed compliance into daily workflows.

4. Auditing & Monitoring

- Lead internal audits of billing activities, coding accuracy, medical documentation, and reimbursement validation.

- Evaluate compliance with Medicare, Medicaid, commercial payer guidelines, and internal quality standards.

- Monitor improper coding patterns, documentation inconsistencies, modifier misuse, and payment variances.

- Track audit findings, implement action plans, and validate post-remediation effectiveness.

5. Training & Education

- Develop and deliver ongoing compliance training programs for clinical, administrative, billing, and coding teams.

- Ensure staff remain updated on regulatory changes, payer mandates, and industry best practices.

- Promote organization-wide compliance culture through awareness programs and competency assessments.

6. Investigations & Issue Resolution

- Lead investigations into reported, suspected, or discovered compliance issues.

- Document findings, determine root causes, and recommend corrective or disciplinary actions.

- Collaborate with HR, Operations, Legal, and leadership to ensure timely resolution and governance.

7. Regulatory & External Audit Management

- Serve as the primary liaison with external regulatory agencies, auditors, and payer investigative teams.

- Manage responses to government inquiries, payer audits, and regulatory examinations.

- Ensure timely submission of required compliance documentation, corrective action reports, and evidence.

8. Corrective & Preventive Action Programs

- Develop corrective action plans (CAPAs) to address identified compliance gaps.

- Track implementation progress and periodically evaluate the effectiveness of remediation activities.

- Work with leadership to enforce accountability across departments.

9. Compliance Reporting & Governance

- Prepare periodic compliance dashboards and reports for senior leadership and the board.

- Communicate audit outcomes, risk levels, training compliance, and overall program health.

- Advise executive leadership on compliance trends, emerging risks, and strategic regulatory impacts.

10. Security, ISO & HIPAA Compliance Oversight

- Coordinate ISO 27001 audit activities and follow-up actions related to quality and information security management.

- Design and implement training programs supporting security and HIPAA compliance.

- Recommend and implement standardized security control documentation, procedures, and governance mechanisms.

Qualifications & Experience

- Bachelors or Masters degree in Healthcare Administration, Compliance, Public Health, or related field.

- 10+ years of experience in healthcare compliance, RCM compliance, coding compliance, or regulatory governance.

- Strong knowledge of CMS regulations, payer policies, HIPAA, and healthcare auditing methodologies.

- Experience managing compliance teams, external audits, and cross-functional governance programs.

- Certifications preferred: CHC, CPC, CPCO, CHPC, CRC, or equivalent.\