Remote RN: Clinical Compliance Auditor

Guide-Health; Philadelphia (Philadelphia County); Remote; USD 82,000 - 87,000; Full time

Benefits offered by this job

Fully remote

Medical, Dental, Vision

401(k) with employer match

Life and Disability insurance

Paid time off

Job summary

Guidehealth is seeking an experienced Registered Nurse to join as Clinical Compliance Auditor II, a remote, full-time role. You will conduct comprehensive audits, monitor UM/PHM plans, and ensure regulatory and client obligations are met while supporting leadership with findings and improvements.

Working autonomously, you’ll develop audit tools, mentor staff, and contribute to governance of compliance programs in a fast-moving, remote-first environment.

Qualifications

• Active, unrestricted 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.
• Minimum of 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 the development and maintenance of the 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 in facilitating 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.

Skills

RN license

Utilization management

Clinical auditing

Regulatory compliance

Independent worker

MS Office

Tools

Excel

Word

Reporting tools

Job description

Guidehealth is seeking an experienced Registered Nurse to join as Clinical Compliance Auditor II, a remote, full-time role. You will conduct comprehensive audits, monitor UM/PHM plans, and ensure regulatory and client obligations are met while supporting leadership with findings and improvements.

Working autonomously, you’ll develop audit tools, mentor staff, and contribute to governance of compliance programs in a fast-moving, remote-first environment.