Job Summary
Position Title: Operational Compliance Lead – RCM & Clinical Documentation (Clinical Background Required)
Reporting to: Chief Administrative Officer
Scope: Essen Health Care & Nursing Home Division only
Job Summary: 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.
Responsibilities
Operational Compliance & Chart Review
- 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.
Clinical Coding & RCM Collaboration
- 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.
Provider & Leadership Education
- 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.
Reporting & CAP Management
- 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.
Qualifications
Qualifications
Required
- 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.
Preferred
- 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.
Core Competencies
Clinical Documentation Integrity • Compliance Auditing • RCM & Revenue Integrity • Provider Education & Coaching • HCC/Risk Adjustment Coding • CAP Development & Closure • Regulatory Compliance • Data Analysis & Reporting • Project Management • Cross-Functional Collaboration
Work Environment
- Full-time | Hybrid or on-site based on business needs | Travel between clinical locations may be required.
The Operational Compliance Lead plays a uniquely important role at the intersection of clinical knowledge, coding expertise, and operational leadership. This is not a corporate oversight role – it is a proactive, hands-on position embedded within Essen Health Care and Nursing Home operations to identify and resolve compliance issues at the source, before they reach external review. If you are a clinically trained professional who understands how care is delivered and how it must be accurately documented and billed, this is a role where your expertise will have immediate, measurable impact.
