Senior RN Clinical Compliance Auditor - Remote

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

Job summary

Guidehealth is seeking an experienced Registered Nurse (RN) to serve as a Clinical Compliance Auditor II in a remote capacity across the United States. This role focuses on ensuring adherence to utilization management, clinical documentation, and regulatory requirements through audits, reporting, and process improvement.

You will monitor UM/PHM plans, MSAs, and client obligations while mentoring other auditors and partnering with Clinical Leadership to strengthen the compliance program.

Qualifications

• Active, unrestricted RN license required.
• Strong knowledge of utilization management processes, clinical documentation, and regulatory compliance requirements.
• 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.
• Proficiency with Microsoft Office, including Excel, Word, and reporting tools.

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, MSAs, 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.
• 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.

Skills

RN license

Utilization management

Clinical auditing

Regulatory compliance

MS Office (Excel/Word)

Job description

Guidehealth is seeking an experienced Registered Nurse (RN) to serve as a Clinical Compliance Auditor II in a remote capacity across the United States. This role focuses on ensuring adherence to utilization management, clinical documentation, and regulatory requirements through audits, reporting, and process improvement.

You will monitor UM/PHM plans, MSAs, and client obligations while mentoring other auditors and partnering with Clinical Leadership to strengthen the compliance program.