Registered Nurse (RN) Clinical Compliance Auditor

Guidehealth • Philadelphia, TX

5d • Remote

About The Position

The Clinical Compliance Auditor II ensures Guidehealth’s clinical operations, utilization management activities, and delegated services comply with regulatory requirements, client contractual obligations, and internal clinical standards. This senior clinical compliance subject matter expert conducts advanced audits, monitoring, and compliance validation to assess adherence to Utilization Management (UM) and Population Health Management (PHM) Plans, Managed Services Agreements (MSAs), and value-based care program requirements.

The role also supports mentorship, process improvement, audit program development, and cross-functional collaboration. Working closely with Clinical Leadership, Compliance, and Operations teams, the auditor identifies risks, supports regulatory readiness, and helps ensure clinical services meet standards for accuracy, quality, and compliance. The position operates with a high degree of autonomy and independent judgment. Guidehealth emphasizes agility, cross-training, ongoing development, and support for cross-functional initiatives as business needs evolve.

This is a fully remote position. Guidehealth provides the equipment needed for the role; employees provide their own internet connection, with a minimum speed of 100 Mbps download and 10 Mbps upload. Employees are expected to be accessible during stated working hours and to join virtual meetings with cameras on. The listed salary is $82,000–$87,000 per year, based on experience and skills.

Requirements

• Active, unrestricted Registered Nurse (RN) license.
• Strong knowledge of utilization management processes, clinical documentation, and regulatory compliance requirements.
• 3–5 years of experience in utilization management, clinical auditing, clinical compliance, or managed care.
• Knowledge of Medicare, Commercial Managed Care, and delegated services compliance requirements.
• Ability to work independently and exercise sound professional judgment.
• Proficiency with Microsoft Office, including Excel, Word, and reporting tools.
• For remote work, provide an internet connection capable of video calls and connecting to internal and external systems, with a minimum speed of 100 Mbps download and 10 Mbps upload.

Nice To Haves

• At least 2 years of clinical compliance auditing or healthcare auditing experience.

Responsibilities

• Conduct comprehensive clinical compliance audits, including audits of utilization management, denial documentation, clinical reporting, authorization compliance, and delegated services requirements.
• Monitor adherence to UM and PHM Plans, Managed Services Agreements, and client-specific contractual and regulatory requirements.
• Perform routine, scheduled, and ad hoc audits to assess compliance with internal policies, regulatory standards, and client obligations.
• Serve as a secondary reviewer for denial documentation to ensure regulatory and contractual compliance.
• Monitor audit findings for trends, risks, and opportunities for operational and compliance improvement.
• Monitor clinical workflows and reporting processes to identify compliance risks, documentation deficiencies, and process gaps.
• Assist in developing and maintaining audit tools, audit protocols, and compliance monitoring frameworks.
• Assist in developing and maintaining UM and PHM Plans and clinical compliance procedures.
• Provide mentorship, guidance, and subject matter expertise to Clinical Compliance Auditors and clinical operations staff.
• Support leadership in identifying training needs and opportunities for clinical compliance improvement.
• Assist with audit reviews, reporting processes, and compliance committee support activities.
• Analyze audit results and clinical data to identify trends, root causes, and opportunities for operational and compliance improvement.
• Prepare and present audit findings and compliance reports to clinical leadership and operational stakeholders.
• Support development of reporting tools, dashboards, and audit metrics to monitor compliance performance.
• Follow security policies and procedures to protect PHI, PII, and Guidehealth intellectual property.
• Disclose secondary employment and remain accessible during stated working hours.

Benefits

• Comprehensive medical insurance plans.
• Dental insurance.
• Vision insurance.
• 401(k) plan with a 3% employer match when the employee contributes 6%.
• Life and disability insurance, with voluntary life insurance options.
• Employee Assistance Program (EAP).
• Paid time off plans.
• Paid parental leave.
• Resources for learning and development.
• Remote work flexibility and company-provided equipment.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed