MEDICARE COMPLIANCE PROGRAM LEAD

Description

Position Overview

The Medicare Compliance Program Lead serves as the primary subject matter expert for Medicare compliance operations, ensuring adherence to CMS regulations, DMEPOS requirements, and organizational standards. This role is responsible for developing and maintaining compliance processes, internal controls, and auditing systems to support intake, documentation, billing readiness, and regulatory requirements.

The position partners with Intake, Revenue Cycle Management (RCM), Customer Care, and Operations to improve documentation accuracy, eligibility verification, billing compliance, and reimbursement outcomes, while supporting scalable workflows and ongoing compliance oversight.

Key Responsibilities

• Administer the Medicare compliance program, ensuring adherence to CMS regulations, Medicare guidelines, and DMEPOS standards
• Audit Medicare-related operational processes, including intake documentation, qualification, re-certification, and billing readiness
• Establish and monitor internal controls and auditing systems to identify compliance risks and operational gaps
• Serve as the primary compliance liaison across Intake, RCM, Customer Care, and Operations to improve Medicare workflows and resolve compliance-related issues.
• Conduct routine audits of patient documentation, billing readiness, and reimbursement processes to ensure regulatory compliance
• Interpret new and revised Medicare regulations and implement process updates to maintain compliance
• Develop and maintain compliance policies, procedures, and documentation standards
• Lead training initiatives and provide ongoing guidance to staff on Medicare documentation requirements, eligibility criteria, and billing standards
• Provide guidance related to audits, denials, and compliance concerns
• Prepare and present compliance reports, audit findings, and risk assessments to leadership
• Identify opportunities for operational improvement and support strategic initiatives related to Medicare growth and compliance scalability
• Provide guidance, onboarding support, and subject matter expertise to new team members as the department expands
• Perform other duties as assigned

Qualifications

• Bachelor’s degree preferred or equivalent combination of education and experience
• Minimum 5 years of healthcare compliance experience, with strong Medicare, CMS, or DMEPOS experience required
• Minimum 2 years of experience leading cross-functional compliance initiatives and operational workflows preferred
• Strong knowledge of Medicare intake, billing, documentation requirements, and reimbursement processes
• Demonstrated ability to interpret complex healthcare regulations and implement operationally effective solutions
• Experience with internal auditing, compliance investigations, and corrective action planning
• Advanced proficiency in Microsoft Office (Word, Excel, Outlook) and Adobe
• Strong analytical, organizational, and problem-solving skills
• Ability to manage multiple priorities in a fast-paced environment
• Must be available to work evenings, weekends, and holidays if needed