Job Summary: The Network Director, Compliance- Billing Integrity is responsible for the strategic design, implementation, and oversight of the WMC Health Network’s enterprise billing compliance auditing and monitoring program. This role provides system-wide leadership for physician and hospital billing integrity, ensuring compliance with federal and state regulatory requirements, including those of the Centers for Medicare and Medicaid Services (CMS), New York State Office of the Medicaid Inspector General (OMIG) and the U.S. Department of Health and Human Services Office of Inspector General (OIG).

The Network Director oversees a multidisciplinary team of auditors and data analysts and manages external audit and consulting relationships. The position is accountable for physician coding audits, hospital inpatient and outpatient auditing activities, proactive monitoring initiatives, and physician education programs. Working in close partnership with Revenue Cycle, Operations, Medical Staff Leadership, and Compliance leadership, this role advances a proactive, data-driven billing compliance model focused on risk mitigation, documentation integrity, and continuous improvement.

Responsibilities: 

Enterprise Audit & Monitoring Oversight

• Lead and oversee the Network’s enterprise billing compliance audit and monitoring program for:
  • Professional (physician) services
  • Hospital inpatient and outpatient services
• Ensure audit scope, methodology, frequency, and documentation align with:
  • NYS OMIG Compliance Program requirements
  • OIG Compliance Program Guidance
  • CMS billing, coding, and documentation standards
• Develop and maintain a risk-based annual audit and monitoring work plan informed by regulatory trends, internal risk assessments, claims data, and enforcement activity.

Physician Coding Audits & Education

• Direct physician coding audit activities, including E/M, procedural, and modifier reviews, across employed and affiliated practices.
• Ensure all physicians receive timely, targeted coding education based on audit findings, regulatory updates, and risk trends.
• Partner with physician leadership, operations, and revenue cycle to design and implement a proactive physician monitoring program that emphasizes education, early intervention, and documentation improvement.
• Oversee onboarding and periodic compliance education for new and existing physicians.

Hospital Auditing Program & External Consultants

• Manage the hospital auditing program, including coordination with external audit and consulting firms.
• Oversee inpatient and outpatient audit activity, including DRG validation, medical necessity, and documentation reviews.
• Ensure consistent methodologies, defensible workpapers, and standardized reporting across internal and external audits.
• Serve as a primary liaison during external audits and regulatory reviews, as directed by Compliance leadership.

Data Analytics, Reporting & Governance

• Oversee data mining, analytics, and monitoring activities to identify billing risk, trends, and outliers.
• Ensure accurate tracking, trending, and validation of audit results, corrective actions, and outcomes.
• Develop dashboards, metrics, and executive-level reports for:
  • Compliance leadership
  • Executive Compliance Committee
  • Board and Board Audit & Corporate Compliance Committee
• Prepare audit summaries and status reports in support of regulatory reporting and governance oversight.

Regulatory Alignment & Continuous Improvement

• Maintain current knowledge of federal and state billing compliance requirements, enforcement trends, and industry best practices.
• Recommend and support policy, procedure, and control enhancements based on audit findings and regulatory developments.
• Collaborate with Compliance, Revenue Cycle, Operations, Legal, and Quality teams to implement corrective action plans and sustainable process improvements.
• Support a culture of compliance through education, transparency, and partnership with operational leaders.

Team Leadership & Management

• Directly supervise and develop a team of compliance auditors and data analysts.
• Ensure appropriate credentials, training, and ongoing competency of auditing staff.
• Establish clear performance expectations, workload prioritization, and professional development pathways

Qualifications/Requirements:

Experience:

• Minimum of 7 years of progressive experience in healthcare compliance, billing compliance, auditing, or revenue integrity, required
• Demonstrated leadership experience managing audit teams and complex compliance programs within a hospital system or large physician enterprise, required
• Experience working with external auditors, consultants, and regulatory agencies, strongly preferred

Education:  

• Bachelor’s degree in healthcare administration, Business Administration, Finance, Accounting, or a related field, required.
• Master’s degree, preferred.

Licenses / Certifications:  

• Certified Professional Coder (CPC), required.
• Additional certifications (e.g., CCS, CHC, CHPC), preferred.

Other: N/A

Special Requirements:

• In-depth knowledge of:
  • CMS billing and coding requirements
  • Federal and New York State healthcare regulations
  • NYS OMIG and OIG compliance program expectations
• Strong analytical, data interpretation, and reporting skills.
• Proven ability to communicate complex compliance concepts to physicians, executives, and operational leaders.
• Demonstrated ability to lead proactive, risk-based compliance initiatives in a large, complex healthcare environment.