Compliance Lead – RCM & Clinical Documentation (Clinical Background Required)
$75,000–$90,000 year
HybridThe Bronx, New York, United States
Job Summary
Conduct routine clinical chart reviews and RCM audits to assess coding accuracy, billing integrity, and documentation completeness across CMS and state-billed services. Proactively monitor compliance risk patterns, generate trend reports, and develop Corrective Action Plans (CAPs) to validate sustained improvement. Apply a clinician's lens to review documentation, ensuring diagnoses and Medical Decision Making support billed codes while serving as the operational liaison between clinical operations and RCM. Deliver targeted education to physicians and staff on documentation best practices and payer-specific regulatory requirements. Produce executive-ready compliance reports and present CAPs to leadership with clear timelines and success metrics. Maintain continuous audit readiness by resolving issues before they escalate to external review.
Required Qualifications
- Bachelor's Degree in Healthcare Administration, Nursing, Health Information Management, Public Health, or related field
- Clinical background
- 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
- Travel between clinical locations may be required
Desired Qualifications
- International Medical Graduate (IMG) or foreign medical degree
- Master's Degree (MHA, MPH, MBA with healthcare focus, MSN, or equivalent)
- 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
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