Remote RN: Clinical Compliance Auditor & Quality Advocate

Guide-Health; Houston (TX); Remote; USD 82,000 - 87,000; Full time

Benefits offered by this job

Work from Home

Medical, Dental, and Vision plans

401(k) with employer match

Paid time off

Job summary

Guidehealth is seeking a Remote RN Clinical Compliance Auditor II to lead advanced auditing of utilization management, PHM plans, and delegated services. The role emphasizes independent judgment, regulatory compliance, and collaboration with Clinical Leadership.

The position is full-time and remote, with a salary range of $82,000 to $87,000 per year, based on experience and skills. A senior clinical compliance expert, you will mentor staff and drive continuous improvement.

Qualifications

• Active, unrestricted RN license required.
• Strong knowledge of utilization management processes and clinical documentation.
• 3–5 years in utilization management, clinical auditing, or managed care.
• Knowledge of Medicare, Commercial Managed Care, and delegated services compliance.

Responsibilities

• Conduct comprehensive clinical compliance audits including UM, denial documentation, and delegated services requirements.
• Monitor adherence to UM and PHM Plans, MSAs, and client obligations.
• Perform routine and ad hoc audits to assess compliance with policies and regulations.
• Serve as secondary reviewer for denial documentation to ensure compliance.
• Monitor audit findings to identify trends, risks, and improvement opportunities.
• Review clinical workflows to detect compliance risks and gaps.
• Develop and maintain audit tools, protocols, and monitoring frameworks.
• Support development of UM and PHM plans and procedures.
• Provide mentorship to Clinical Compliance Auditors and staff.
• Identify training needs for clinical compliance improvement.
• Facilitate audit reviews and reporting processes.

Skills

RN license

Utilization management

Clinical auditing

Regulatory compliance

Independent judgment

Tools

Microsoft Office

Job description

Guidehealth is seeking a Remote RN Clinical Compliance Auditor II to lead advanced auditing of utilization management, PHM plans, and delegated services. The role emphasizes independent judgment, regulatory compliance, and collaboration with Clinical Leadership.

The position is full-time and remote, with a salary range of $82,000 to $87,000 per year, based on experience and skills. A senior clinical compliance expert, you will mentor staff and drive continuous improvement.