Vice President Compliance

PathWell - Home Health and Hospice Care; Connecticut; On-site; USD 170,000 - 230,000; Full time

Benefits offered by this job

Bonus opportunity

Health, dental, vision, 401(k), and PТ

Job summary

PathWell Health is seeking a VP of Compliance to own the internal QA function and lead the QA team across the US and offshore. You will ensure every chart, claim, and process meets standards applied by MAC, UPIC, or state surveyors, bridging clinical documentation, billing, and regulatory readiness.

This role sits at the intersection of clinical documentation, billing/RCM, and QAPI; you will catch issues pre-payment, defend during surveys, and ensure fixes persist through QAPI initiatives.

Qualifications

• 8+ years in home health compliance, QA, or revenue integrity.
• 3+ years leading a team.
• Hands-on ADR and TPE audits end to end, including appeals.
• Deep knowledge of Medicare CoPs (42 CFR 484), PDGM, OASIS-E, MAC guidelines.
• Led an agency through state or CMS surveys with accepted plans of correction.
• Built or ran a QAPI program with measurable PIPs.
• Comfortable with data: build audit samples, read denial trends, present findings.

Responsibilities

• Lead and develop the QA team; set review standards, sampling methodology, and productivity and accuracy targets
• Run QA as an independent audit function: pre-bill and post-bill chart reviews, OASIS accuracy, plan of care, orders, and visit documentation
• Build audit scorecards by clinician, branch, and state; report trends and risk to leadership monthly
• Partner with our product team on QA tooling, setting the rules and review logic the tools enforce
• Own the response process for ADRs, TPE, SMRC, RAC, UPIC, and other medical review activity, from record assembly through appeals
• Audit claims against documentation before billing: F2F, homebound status, skilled need, signed orders, PDGM coding and grouping, LUPA thresholds, and NOA timeliness
• Track denial rates and root causes by payer and branch; drive corrective action with intake, clinical, and billing teams
• Monitor PEPPER, CBR, and MAC-specific trends, and adjust audit focus accordingly
• Keep every location survey-ready for state, CMS, and accreditation surveys (Conditions of Participation)
• Lead survey response, plans of correction, and follow-up across all four states
• Run mock surveys and focused audits on high-risk CoPs (patient rights, care planning, infection control, aide supervision, clinical records)
• Track federal and state regulatory changes (CMS final rules, MAC LCDs, state licensure rules) and translate them into policy and training
• Own the QAPI program: data-driven PIPs, quality committee, and documented outcomes
• Oversee HHVBP, HHCAHPS, and Care Compare performance with clinical leadership
• Maintain the compliance program: policies, training, hotline, investigations, exclusion screening, and OIG guidance alignment
• Serve as the internal point of contact for outside counsel and consultants on compliance matters

Skills

QA leadership

Internal audit

Regulatory compliance

Data analysis

ADR audits

TPE audits

OASIS accuracy

PDGM knowledge

MAC guidelines

QAPI program

Denials trends

Offshore teams

Tools

WellSky/Kinnser

Job description

PathWell Health is a technology-enabled, Medicare-certified home health company operating in California, Connecticut, Virginia, and West Virginia, with a smaller hospice operation in Virginia. We have 240+ clinicians, a census of 1,600+ patients, and an in-house product team building our own QA and intake tools. We are growing, and we want compliance built into how we operate rather than bolted on after the fact.

The role

The VP of Compliance owns PathWell's internal QA function and runs it the way an external auditor would. You will lead our QA team (US and offshore) and hold every chart, claim, and process to the standard a MAC, UPIC, or state surveyor would apply.

This role sits at the intersection of clinical documentation, billing/RCM, and regulatory survey readiness. You will catch problems before payers and surveyors do, defend us when they come, and make sure fixes stick through QAPI.

Responsibilities

QA leadership and internal audit

• Lead and develop the QA team; set review standards, sampling methodology, and productivity and accuracy targets
• Run QA as an independent audit function: pre-bill and post-bill chart reviews, OASIS accuracy, plan of care, orders, and visit documentation
• Build audit scorecards by clinician, branch, and state; report trends and risk to leadership monthly
• Partner with our product team on QA tooling, setting the rules and review logic the tools enforce

Billing and RCM compliance

• Own the response process for ADRs, TPE, SMRC, RAC, UPIC, and other medical review activity, from record assembly through appeals
• Audit claims against documentation before billing: F2F, homebound status, skilled need, signed orders, PDGM coding and grouping, LUPA thresholds, and NOA timeliness
• Track denial rates and root causes by payer and branch; drive corrective action with intake, clinical, and billing teams
• Monitor PEPPER, CBR, and MAC-specific trends, and adjust audit focus accordingly

Survey readiness and regulatory compliance

• Keep every location survey-ready for state, CMS, and accreditation surveys (Conditions of Participation)
• Lead survey response, plans of correction, and follow-up across all four states
• Run mock surveys and focused audits on high-risk CoPs (patient rights, care planning, infection control, aide supervision, clinical records)
• Track federal and state regulatory changes (CMS final rules, MAC LCDs, state licensure rules) and translate them into policy and training

QAPI and compliance program

• Own the QAPI program: data-driven PIPs, quality committee, and documented outcomes
• Oversee HHVBP, HHCAHPS, and Care Compare performance with clinical leadership
• Maintain the compliance program: policies, training, hotline, investigations, exclusion screening, and OIG guidance alignment
• Serve as the internal point of contact for outside counsel and consultants on compliance matters

Requirements

Must have

• 8+ years in home health compliance, QA, or revenue integrity, with 3+ years leading a team
• Hands-on experience managing ADR and TPE audits end to end, including appeals through the QIC/ALJ level
• Deep working knowledge of Medicare CoPs (42 CFR 484), PDGM, OASIS-E, Medicare Benefit Policy Manual Ch. 7, and MAC guidelines (Palmetto GBA, NGS, or CGS)
• Has led an agency through state and/or CMS surveys and written accepted plans of correction
• Built or run a QAPI program with measurable PIP results
• Comfortable with data: can build an audit sample, read denial trends, and present findings to leadership

Strongly preferred

• RN license, or clinical background with deep coding expertise
• Experience with WellSky/Kinnser
• Some hospice exposure is a plus, not required
• Experience managing offshore or distributed teams

What success looks like in year one

• A documented, risk-based audit plan covering every location, with results reported monthly
• ADR and TPE responses submitted on time, with improving approval rates
• Clean or minimal-deficiency surveys, and no repeat findings
• Pre-bill audit catching documentation gaps before claims go out, with denial rates trending down
• An active QAPI program with at least two completed PIPs tied to measurable outcomes

Compensation

• We offer competitive salary, plus bonus tied to audit, survey, and denial outcomes.
• Benefits include health, dental, vision, 401(k), and PTO.