Registered Nurse (RN) Clinical Compliance Auditor- 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, conducting advanced audits, monitoring, and compliance validation to confirm adherence to Utilization Management (UM) and Population Health Management (PHM) Plans, Managed Services Agreements (MSAs), and value-based care program requirements. The position also contributes leadership through mentorship, process improvement, audit program development, and cross-functional collaboration. It partners with Clinical Leadership, Compliance, and Operations to identify risks, support regulatory readiness, and uphold the accuracy, quality, and compliance of clinical services. The role works with a high degree of autonomy and independent judgment to evaluate compliance risks and strengthen clinical compliance processes. Guidehealth is a fully remote company. Employees are expected to adapt to changing business needs, support cross-functional initiatives, and work collaboratively across the organization. The company provides role-related equipment; employees provide an internet connection with at least 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.
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.
- Provide an internet connection capable of video calls and system access, with a minimum 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 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 to detect compliance risks, documentation deficiencies, or 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 the 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 arrangement.
- Comprehensive medical, dental, and vision plans.
- 401(k) plan with a 3% employer match when the employee contributes 6%.
- Life and disability insurance, plus voluntary life insurance options.
- Employee Assistance Program (EAP).
- Paid time off plans.
- Paid parental leave.
- Learning and development resources.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
No Education Listed
