Registered Nurse (RN) Clinical Compliance Auditor- Remote

Guidehealth; EE. UU.; A distancia; USD 82.000 - 87.000; Jornada completa

Descripción de la vacante

Guidehealth seeks a Clinical Compliance Auditor II to lead advanced audits of utilization management, PHM, and delegated services, ensuring regulatory alignment and contract compliance across clinical operations.

You will mentor staff, develop audit protocols, and partner with Clinical Leadership, Compliance, and Operations to drive improvements. RN licensure and 3–5 years in clinical auditing are required; salary ranges from $82,000 to $87,000 per year.

Formación

• Active RN license required.
• 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.
• Ability to work independently and exercise sound professional judgment.
• Proficiency with Microsoft Office, including Excel and Word.

Responsabilidades

• Conduct comprehensive clinical compliance audits including utilization management, denial documentation, clinical reporting, authorization compliance, and delegated services.
• Monitor adherence to UM and PHM Plans, MSAs, and client-specific contractual and regulatory requirements.
• Perform routine, scheduled and ad hoc audits to assess compliance with internal policies and regulatory standards.
• Serve as a secondary reviewer for denial documentation to ensure regulatory and contractual compliance.
• Monitor audit findings to identify trends, risks, and opportunities for improvement.
• Assist in developing and maintaining audit tools, protocols, and compliance monitoring frameworks.
• Provide mentorship and subject matter expertise to Clinical Compliance Auditors and staff.

Conocimientos

RN license

Utilization management

Clinical auditing

Regulatory compliance

MS Office proficiency

Herramientas

Excel

Word

PowerPoint

Descripción del empleo

The Clinical Compliance Auditor II is responsible for ensuring Guidehealth's clinical operations, utilization management activities, and delegated services comply with regulatory requirements, client contractual obligations, and internal clinical standards. This role serves as a senior clinical compliance subject matter expert and performs advanced auditing, monitoring, and compliance validation activities to ensure 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, this role provides leadership through mentorship, process improvement, audit program development, and cross-functional collaboration. The Clinical Compliance Auditor II partners closely with Clinical Leadership, Compliance, and Operations teams to identify risks, support regulatory readiness, and ensure clinical services meet the highest standards of accuracy, quality, and compliance.

This position operates with a high degree of autonomy, exercising independent judgment to evaluate compliance risks, support operational improvements, and strengthen Guidehealth's clinical compliance infrastructure.

As a growing and innovative organization, we operate with a high degree of agility. Employees are expected to adapt to evolving business needs, step in to support cross-functional initiatives, and contribute beyond traditional role boundaries when needed. This collaborative and flexible mindset is essential to our success. We encourage cross-training, ongoing development, and a commitment to learning across all areas of the business-ensuring we continue to grow as a high-performing, mission-driven team and you continue to grow and thrive as a member of our high-performing, mission-mission driven team.

What you'll be doing

• Conducting comprehensive clinical compliance audits, including utilization management, denial documentation, clinical reporting, authorization compliance, and delegated services requirements.
• Monitoring adherence to UM and PHM Plans, Managed Services Agreements, and client-specific contractual and regulatory requirements.
• Performing routine, scheduled, and ad hoc audits to assess compliance with internal policies, regulatory standards, and client obligations.
• Serving as a secondary reviewer for denial documentation to ensure regulatory and contractual compliance.
• Monitoring audit findings to identify trends, risks, and opportunities for operational and compliance improvement.
• Monitoring clinical workflows and reporting processes to detect compliance risks, documentation deficiencies, or process gaps.
• Assisting in developing and maintaining audit tools, audit protocols, and compliance monitoring frameworks.
• Assisting in the development and maintenance of the UM and PHM Plans and clinical compliance procedures.
• Providing mentorship, guidance, and subject matter expertise to Clinical Compliance Auditors and clinical operations staff.
• Supporting leadership in identifying training needs and opportunities for clinical compliance improvement.
• Assisting in facilitating audit reviews, reporting processes, and compliance committee support activities.
• Analyzing audit results and clinical data to identify trends, root causes, and opportunities for operational and compliance improvement.
• Preparing and presenting audit findings and compliance reports to clinical leadership and operational stakeholders.
• Supporting the development of reporting tools, dashboards, and audit metrics to monitor compliance performance.

What you'll need for success

• Active, unrestricted Registered Nurse (RN) license required.
• Strong knowledge of utilization management processes, clinical documentation, and regulatory compliance requirements.
• Minimum of 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.

What we'd love for you to have

• Minimum of 2 years of clinical compliance auditing or healthcare auditing experience.

The salary for this role is $82,000.00 to $87,000.00 per year based upon experience and skills.

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We are Driven by A ccountability - grounded in transparency, reliability, and integrity as we navigate challenges and opportunities alike.

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