Registered Nurse (RN) Clinical Compliance Auditor

Guidehealth • Houston, 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. The role serves as a senior clinical compliance subject matter expert, performing advanced auditing, 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.

In addition to conducting audits, the position supports audit program development, process improvement, mentorship, and cross-functional collaboration. It partners with Clinical Leadership, Compliance, and Operations to identify risks, support regulatory readiness, and help ensure clinical services meet standards for accuracy, quality, and compliance. The role operates with a high degree of autonomy and independent judgment. Employees are also expected to adapt to evolving business needs and contribute to cross-functional initiatives as needed.

Guidehealth is a fully remote company. The company provides role-related equipment; employees provide their own internet connection, with a minimum required speed of 100 Mbps download and 10 Mbps upload. Employees must be accessible during stated working hours and are asked to join virtual meetings with cameras on. The role is responsible for following security policies and procedures to protect patient and company data.

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 access to internal and external systems, with minimum speeds 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 covering 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 to identify trends, risks, and opportunities for operational and compliance improvement.
• Monitor clinical workflows and reporting processes for 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 improvement opportunities.
• 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 any secondary employment and remain accessible during stated working hours.

Benefits

• Fully remote work.
• Medical, dental, and vision plans.
• 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.
• Learning and development resources.
• Company-provided equipment for the role at no charge.

What This Job Offers

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