Director, Compliance and External Audit at Visiting Nurse Service of New York d/b/a VNS Health
Visiting Nurse Service of New York d/b/a VNS Health · New York, United States Of America · Onsite
- Senior
- Office in New York
Overview:Directs the response to audits related to Medicare and Medicaid billing compliance for VNS Health's provider lines of business – i.e., VNS Health Home Care, VNS Health Hospice Care, VNS Health Behavioral Health, VNS Health Personal Care, and Medical Care at Home, P.C. Ensures regulatory adherence in the delivery of home health, hospice, and behavioral health services, with particular expertise in claims review and submission, denial management, claim reversals, and administrative appeals. Directs Compliance-program activities related to internal and external audits, policy and procedure development, trainings and education, and related projects. Directs regulatory review and coordinates with Legal for all required self-disclosures to government and other payors.Serves as a high-level subject matter expert on Medicare and New York State Medicaid billing regulations and plays a critical role in protecting revenue integrity and mitigating compliance risk. Works cross-functionally with compliance operations, clinical operations, quality, education, and revenue cycle teams, provides strategic guidance on clinical documentation risk, and leads the response to major external audits—including those conducted by CMS, the New York State Department of Health (NYSDOH), and the New York State Office of the Medicaid Inspector General (OMIG). Develops and drafts clear, persuasive clinical and regulatory arguments in response to claim denials and disallowances. Works under general supervision.Responsibilities:
What We Provide
- Referral bonus opportunities
- Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
- Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability
- Employer-matched retirement saving funds
- Personal and financial wellness programs
- Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
- Generous tuition reimbursement for qualifying degrees
- Opportunities for professional growth and career advancement
- Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities
What You Will Do
- Directs complex, large-scale condition of payment and related audits from federal and state agencies (e.g., CMS, NYSDOH, OMIG, UPICs, MACs). Oversees response to routine audits including RACs and CERTS, working in close collaboration with the line of business Directors responsible for regulatory compliance and performance improvement, as well as the corporate Quality and Education departments.
- For audits managed by the Compliance and Legal teams, serve as project manager for all phases of the audit lifecycle, ensuring strategic coordination, documentation readiness, and effective cross-functional collaboration. Analyzes audit findings and identify grounds for rebuttal based on medical necessity, documentation sufficiency, and regulatory interpretation.
- Acts as the primary Compliance liaison to auditors and government regulators for condition of payment and related audits, reports, and related inquiries. Provides support for other surveys, reports, and inquiries that are managed by quality and operational teams.
- Drafts clear, concise, and persuasive appeals, position statements, and rebuttals grounded in clinical and legal reasoning.
- Coordinates with legal, clinical, quality, education, and revenue cycle teams to strengthen submissions and to support overturning and mitigating compliance-managed audit findings or claim denials. Oversees related billing denial management, appeal workflows, and root cause analysis of disallowances.
- Ensures compliant billing practices for all Medicare and Medicaid claims, including New York-specific rules for home health, hospice, and behavioral health services.
- Partners with billing and clinical teams to prevent repeat errors and ensure accurate coding and documentation.
- Manages end-to-end processes for self-disclosures and self-reports to government and other payors, under the direction of the Legal Department. Ensures all disclosures and reports are tracked and provides reports and analysis to the Legal Department, Audit Committee and Provider Boards, leadership, and other department as appropriate.
- Maintains expert-level knowledge of federal and New York State Medicaid billing, documentation, and audit requirements; supports maintenance of regulatory reference library for use by department and across departments.
- Analyzes and communicates regulatory changes and enforcement trends to stakeholders; coordinates with legal on regulatory interpretation issues.
- Serves as a trusted advisor on complex clinical compliance matters across operational units.
- Collaborates with others in Compliance, clinical operations, quality, education, and revenue cycle departments to integrate compliance into workflows and quality initiatives.
- Provides strategic guidance to clinical leaders on documentation practices that support defensible billing and audit readiness.
- Identifies high-risk documentation patterns and lead remediation efforts.
- Directs key Compliance team activities, including internal documentation and billing audits to proactively identify risks. Coordinates appropriate responses with others in Compliance, including designing recommended corrective actions plans and monitoring short and long-term remediation steps. Further support appropriate updates to Policies & Procedures, in coordination with Legal, Legal Operations, and others in Compliance.
- Develops and implements effective training and education on new regulatory updates as well as identified gaps in regulatory knowledge. Collaborates with Compliance education team to ensure annual training reflects regulatory updates and risks identified through risk assessment processes.
- Shares key metrics and findings to senior compliance leadership and executive stakeholders. Prepares reports for the Compliance Committee and other leadership meetings as well as updates to the Boards of Directors and Audit Committee of the Board.
- Develops and delivers targeted training on audit preparedness, documentation standards, and billing compliance requirements.
- Promotes a culture of accountability and documentation excellence across clinical programs.
- Maintains thorough records of audit responses, appeal submissions, outcomes, and internal assessments.
- Generates reports and dashboards to communicate compliance risks, trends, and performance indicators.
- Participates in special projects and performs other duties as assigned.
Licenses and Certifications:
- Professional license and current registration to practice as a Registered Nurse, Physical Therapist, Occupational Therapist, Speech Language Pathologist, or Social Worker in New York State required.
- Professional certifications such as CHC (Certified in Healthcare Compliance), CPC (Certified Professional Coder), or equivalent, or a Juris Doctorate preferred
Education:
- Bachelor's Degree in Nursing or other clinical field, Health Information Management, Healthcare Administration, or related field required
- Master's Degree in Nursing or other clinical field, Health Information Management, Healthcare Administration, or related field preferred
Work Experience:
- Minimum of 6 years of experience in healthcare compliance, clinical documentation auditing, or regulatory oversight required
- Demonstrated mastery of Medicare and New York Medicaid billing, audit, and appeal regulations required
- Knowledge of federal and state health care compliance laws, regulations and requirements required; knowledge and experience with compliance requirements applicable to VNS Health clinical services required
- Direct experience responding to audits from CMS, NYSDOH, OMIG, and other oversight agencies is required
- Experience with home health, hospice, or mental health services required
- Demonstrated success in managing complex audit responses and writing effective appeals required
