Remote RN: Clinical Compliance Auditor (UM/PHM)

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

Benefits offered by this job

Work from Home

Medical, Dental, Vision plans

Paid time off & parental leave

401(k) with employer match

Job summary

Guidehealth is hiring a Registered Nurse (RN) Clinical Compliance Auditor II for a remote, full-time role. You will conduct comprehensive audits, monitor adherence to UM/PHM plans and client obligations, and lead audit programs with senior clinical leadership.

The position emphasizes independent judgment, mentorship, and process improvement across clinical operations. Ideal candidates bring 3–5 years in utilization management or clinical compliance, strong regulatory knowledge, and proficiency

Qualifications

• Active, unrestricted RN license required.
• Strong knowledge of utilization management, clinical documentation, and regulatory compliance requirements.
• 3–5 years 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, Word, and reporting tools.

Responsibilities

• Conduct comprehensive clinical compliance audits including UM, denial documentation, and delegated services requirements.
• Monitor adherence to UM and PHM plans, MSAs, and client regulatory obligations.
• Perform routine, scheduled, and ad hoc audits to assess compliance with policies and standards.
• Serve as a secondary reviewer for denial documentation to ensure compliance.
• Monitor audit findings to identify trends, risks, and opportunities for improvement.
• Develop and maintain audit tools, protocols, and monitoring frameworks.
• Mentor Clinical Compliance Auditors and clinical operations staff.

Skills

RN license

Utilization management

Clinical auditing

Regulatory compliance

Independent judgment

MS Office (Excel and Word)

Tools

Excel

Word

Reporting tools

Job description

Guidehealth is hiring a Registered Nurse (RN) Clinical Compliance Auditor II for a remote, full-time role. You will conduct comprehensive audits, monitor adherence to UM/PHM plans and client obligations, and lead audit programs with senior clinical leadership.

The position emphasizes independent judgment, mentorship, and process improvement across clinical operations. Ideal candidates bring 3–5 years in utilization management or clinical compliance, strong regulatory knowledge, and proficiency