Head of Compliance

Accountabilities
Lead healthcare compliance strategy: Develop, implement, and maintain a comprehensive compliance framework aligned with applicable Centers for Medicare & Medicaid Services (CMS) requirements, Office of Inspector General (OIG) guidance, state regulations, and commercial payer policies.
Oversee PC-MSO compliance: Ensure the organization's professional corporation and management services organization structure complies with applicable requirements, including management services agreements, state-specific corporate practice of medicine rules, fair-market-value fees, and the separation of clinical and business decision-making.
Manage HIPAA privacy and security: Lead the organization's privacy and security program, including policy development, risk assessments, business associate agreements (BAAs), workforce training, access reviews, incident management, and breach response.
Audit coding and billing practices: Review Medicare Part B coding and billing for care management, evaluation and management (E&M), and related services to verify that documentation, time requirements, and claim submissions meet applicable standards.
Oversee revenue cycle compliance: Evaluate end-to-end revenue cycle management processes, including eligibility verification, claim submission, denial management, appeals, patient cost-sharing collection, waiver practices, and overpayment identification and refunds.
Monitor regulatory developments: Track annual Medicare Physician Fee Schedule updates, National Correct Coding Initiative (NCCI) edits, Medicare Administrative Contractor (MAC) guidance, OIG Work Plan priorities, enforcement actions, and evolving Medicaid and commercial payer requirements.
Prevent fraud, waste, and abuse: Establish safeguards against violations of the Anti-Kickback Statute, Stark Law, False Claims Act, and beneficiary-inducement restrictions, particularly in patient outreach, enrollment, referral relationships, and partnership arrangements.
Build and maintain the compliance program: Develop and oversee a structured program based on OIG General Compliance Program Guidance, incorporating written policies, employee education, monitoring, audits, reporting channels, and regular updates to leadership.
Translate regulations into actionable guidance: Explain complex regulatory requirements in clear, practical terms and help teams understand their implications for clinical operations, billing practices, product development, and business decisions.
Embed compliance into technology: Partner with engineering and product teams to integrate regulatory requirements, privacy safeguards, documentation standards, and compliance controls directly into software and operational workflows.
Provide compliance training and guidance: Educate employees and relevant stakeholders on regulatory obligations, internal policies, billing standards, privacy practices, and procedures for reporting potential violations.
Investigate and remediate compliance issues: Identify potential gaps, assess risks, recommend corrective actions, and oversee remediation to prevent recurring issues and strengthen organizational accountability.
Advise executive leadership: Provide clear assessments of compliance risks, emerging regulatory changes, audit findings, and recommended actions to support informed strategic decision-making.
Support scalable growth: Ensure compliance processes evolve alongside changes in healthcare services, reimbursement models, technology, and geographic expansion.

Requirements

Professional experience: At least seven years of experience in healthcare compliance, with substantial hands-on responsibility for Medicare Part B billing and coding.
Medicare and payer expertise: Deep working knowledge of Medicare, Medicaid, and commercial insurance requirements, including reimbursement policies, documentation standards, coding rules, claims processing, and payer-specific regulations.
PC-MSO experience: Direct experience working with a professional corporation and management services organization structure, or a comparable physician-practice management model.
Healthcare regulatory knowledge: Strong understanding of HIPAA, the Anti-Kickback Statute, Stark Law, and the False Claims Act, including their practical implications for healthcare operations and business arrangements.
Coding and reimbursement expertise: Familiarity with Medicare coding requirements and reimbursement changes affecting care management, E&M services, telehealth, and remote monitoring. Ability to understand how codes are introduced, revised, bundled, revalued, or retired and how these changes affect compliance.
Revenue cycle management experience: Practical knowledge of eligibility verification, claim submission, denials, appeals, patient cost-sharing, waiver restrictions, and overpayment refunds.
Compliance program management: Experience developing and operating compliance programs that include policies, risk assessments, audits, monitoring, workforce education, incident reporting, and corrective action plans.
Regulatory monitoring and interpretation: Ability to stay current with CMS rulemaking, the annual Physician Fee Schedule, NCCI edits, MAC guidance, OIG enforcement priorities, and state and commercial payer updates.
Privacy and security knowledge: Experience managing HIPAA compliance, privacy and security risk assessments, vendor agreements, access controls, workforce training, and breach response.
Preferred professional certifications: Certifications such as Certified in Healthcare Compliance (CHC), Certified in Healthcare Privacy Compliance (CHPC), Certified Professional Coder (CPC), or Certified Professional Compliance Officer (CPCO) are advantageous.
Preferred clinical services experience: Familiarity with Chronic Care Management (CCM), Principal Care Management (PCM), Advanced Primary Care Management (APCM), Behavioral Health Integration (BHI), remote patient monitoring, or telehealth services.
Managed care experience: Experience working with Medicare Advantage and Medicaid managed care plans across multiple states is preferred.
Legal and advisory background: A Juris Doctor (JD) degree or experience working closely with healthcare legal counsel is an advantage.
Technology collaboration: Ability to work effectively with engineers, product managers, clinical teams, and operational stakeholders to incorporate compliance requirements into software and business processes.
Analytical and risk-management skills: Strong judgment and attention to detail, with the ability to identify material compliance risks, prioritize remediation, and develop practical, proportionate solutions.
Communication skills: Excellent written and verbal communication skills, including the ability to explain complex regulatory issues in accessible language and provide clear recommendations that teams can implement.
Startup adaptability: Comfortable working in a fast-moving, evolving environment, balancing strategic leadership with hands-on execution and adapting compliance processes as the organization grows.
Professional integrity: Demonstrated discretion, accountability, independence, and commitment to ethical conduct and patient-centered healthcare delivery.

Benefits

Flexible part-time arrangement: Fractional leadership opportunity with flexible working hours.
Remote work: Work remotely from within the United States.
Strategic leadership impact: Shape the compliance strategy and regulatory foundation of a growing, technology-enabled healthcare organization.
Broad organizational influence: Collaborate with clinical, operational, legal, and technical teams to embed compliance throughout healthcare delivery and software development.
Innovation-focused environment: Help integrate regulatory safeguards into technology-enabled care models and evolving healthcare workflows.
Meaningful mission: Contribute to improving how Medicare patients navigate healthcare and access appropriate care and support.
Professional growth: Apply and expand expertise across healthcare regulation, reimbursement, privacy, revenue cycle management, and compliance program development.

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