Senior RN — Clinical Compliance & Audit Leader

Guidehealth; USA; Remote; USD 82.000 - 87.000; Vollzeit

Zusammenfassung

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.

Qualifikationen

• 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.

Aufgaben

• 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.

Kenntnisse

RN license

Utilization management

Clinical auditing

Regulatory compliance

MS Office proficiency

Tools

Excel

Word

PowerPoint

Jobbeschreibung

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.