Clinical Compliance Auditor Remote

The Clinical Compliance Auditor II is responsible for ensuring Guidehealths clinical operations utilization management activities and delegated services comply with regulatory requirements client contractual obligations and internal clinical standards. This role serves as a senior clinical compliance subject matter expert and performs advanced auditing monitoring and compliance validation activities to ensure adherence to Utilization Management (UM) and Population Health Management (PHM) Plans Managed Services Agreements (MSAs) and value-based care program requirements.

In addition to conducting audits this role provides leadership through mentorship process improvement audit program development and cross-functional collaboration. The Clinical Compliance Auditor II partners closely with Clinical Leadership Compliance and Operations teams to identify risks support regulatory readiness and ensure clinical services meet the highest standards of accuracy quality and compliance.
This position operates with a high degree of autonomy exercising independent judgment to evaluate compliance risks support operational improvements and strengthen Guidehealths clinical compliance infrastructure.

As a growing and innovative organization we operate with a high degree of agility. Employees are expected to adapt to evolving business needs step in to support cross-functional initiatives and contribute beyond traditional role boundaries when needed. This collaborative and flexible mindset is essential to our success. We encourage cross-training ongoing development and a commitment to learning across all areas of the businessensuring we continue to grow as a high-performing mission-driven team and you continue to grow and thrive as a member of our high-performing mission-mission driven team.

What youll be doing

• Conducting comprehensive clinical compliance audits including utilization management denial documentation clinical reporting authorization compliance and delegated services requirements.
• Monitoring adherence to UM and PHM Plans Managed Services Agreements and client-specific contractual and regulatory requirements.
• Performing routine scheduled and ad hoc audits to assess compliance with internal policies regulatory standards and client obligations.
• Serving as a secondary reviewer for denial documentation to ensure regulatory and contractual compliance.
• Monitoring audit findings to identify trends risks and opportunities for operational and compliance improvement.
• Monitoring clinical workflows and reporting processes to detect compliance risks documentation deficiencies or process gaps.
• 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.
• Supporting leadership in identifying training needs and opportunities for clinical compliance improvement.
• Assisting in facilitating audit reviews reporting processes and compliance committee support activities.
• Analyzing audit results and clinical data to identify trends root causes and opportunities for operational and compliance improvement.
• Preparing and presenting audit findings and compliance reports to clinical leadership and operational stakeholders.
• Supporting the development of reporting tools dashboards and audit metrics to monitor compliance performance.

Qualifications :

What youll need for success

• Active unrestricted Registered Nurse (RN) license required.
• Strong knowledge of utilization management processes clinical documentation and regulatory compliance requirements.                                                                                                                 
• Minimum of 35 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.         

What wed love for you to have                                                                                                                          

• Minimum of 2 years of clinical compliance auditing or healthcare auditing experience.

Additional Information :

The salary for this role is $82000.00 to $87000.00 per year based upon experience and skills.

ALIVE with Purpose: How We Thrive at Guidehealth 

At Guidehealth our values come to life in everything we do. 

• We are Driven by Accountability grounded in transparency reliability and integrity as we navigate challenges and opportunities alike. 
• Always Growing Always Learning staying curious and continuously improving inspires us to shape a better future for healthcare. 
• With Collaborative Innovation we solve problems creatively making every experience better for our employees and the patients we serve. 
• At Guidehealth Every Voice Matters we believe our collective strength is rooted in the unique perspectives of each team member. 
• And through Empathy in Action we build stronger connections with those who count on us. 
• This is what it means to be ALIVE with purpose. This is how we thrive together at Guidehealth. 

BENEFITS:

While you are hard at work advancing value-based healthcare we are here to ensure YOU have the care you and your family need and the opportunities for growth and development. Our commitments to you include:

• Work from Home: Guidehealth is a fully remote company providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs.
• Keep Health a Priority: We offer comprehensive Medical Dental and Vision plans to keep you covered.
• Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution.
• Have Peace of Mind: We provide Life and Disability insurance for those just in case moments. Additionally we offer voluntary Life options to keep you and your loved ones protected.
• Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times.
• Take Time for Yourself: We offer paid time off plans helping you achieve work-life balance and meet your personal goals.
• Support Your New Family: Welcoming a new family member takes time and commitment. Guidehealth offers paid parental leave to give you the time you need.
• Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us.

All full-time employees of Guidehealth who work 30 hours per week or more are eligible for our comprehensive benefits package. Temporary employees and contractors are not eligible for benefits.

COMPENSATION:

The listed compensation range listed is paid bi-weekly per our standard payroll practices. Final base pay decisions are dependent upon a variety of factors which may include but are not limited to: skill set years of relevant experience education location and licensure/certifications.

OUR COMMITMENT TO EQUAL OPPORTUNITY EMPLOYMENT 

Diversity inclusion and belonging are at the core of Guidehealths values. We are an equal opportunity employer. We enthusiastically accept our responsibility to make employment decisions without regard to race religious creed color age sex sexual orientation and identity national origin citizenship religion marital status familial status physical sensory or medical disability Family and Medical Leave military or veteran status pregnancy childbirth or other related medical conditions or any other classification protected by federal state and local laws and ordinances. Our management is fully dedicated to ensuring the fulfillment of this policy with respect to hiring placement promotion transfer demotion layoff termination recruitment advertising pay and other forms of compensation training and general treatment during employment. 

OUR COMITTMENT TO PROTECTION OF PATIENT AND COMPANY DATA

This position is responsible for following all Security policies and procedures in order to protect all PHI and PII under Guidehealths custodianship as well as Guidehealth Intellectual Properties.  For any security-specific roles the responsibilities would be further defined by the hiring manager. 

As a remote-first organization handling sensitive healthcare data Guidehealth verifies candidate identity at multiple stages of the hiring and onboarding to safeguard patient privacy data security and compliance requirements.

REMOTE WORK TECHNICAL REQUIREMENTS

Guidehealth is a fully remote company. We provide new employees with the necessary equipment to function in their role at no charge to the employee. Employees provide their own internet connection capable of conducting video calls on camera and connecting to various internal and external systems. The required internet speed is a minimum of 100 mbps download 10 mbps upload. Please run a speed test here to confirm your internet connection meets these requirements. 

SECONDARY EMPLOYMENT

At Guidehealth we value transparency and collaboration as part of our commitment to excellence. As your primary employer we kindly ask all team members to disclose any secondary employment regardless of whether it may present a potential conflict of interest. 

To ensure smooth teamwork and availability employees must be accessible during our stated working hours. We foster connection and engagement by asking team members to join virtual meetings with their cameras on.

Remote Work :

Yes

Employment Type :

Full-time