Clinical Compliance Auditor

Guidehealth is a data-powered healthcare company focused on operational excellence, affordable care, and improved patient outcomes. The Clinical Compliance Auditor II conducts advanced audits and compliance validation across clinical operations, utilization management, population health management, delegated services, and value-based care programs. The role also provides mentorship, develops audit processes, analyzes risks and trends, and collaborates with clinical leadership, compliance, and operations teams.

Responsibilities

• 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

Benefits

• 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.
• Comprehensive Medical, Dental, and Vision plans.
• 401(k) plan includes a 3% employer match to your 6% contribution.
• Life and Disability insurance.
• Voluntary Life options.
• Employee Assistance Program (EAP).
• Paid time off plans.
• Paid parental leave.
• Various resources dedicated to 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 the comprehensive benefits package.
• Guidehealth provides new employees with the necessary equipment to function in their role at no charge to the employee.

Company

• AI healthcare platform for value-based care providers
• Dallas, Texas, USA
• https://guidehealth.com/
• Founded in 2023
• 201-500 employees

Qualifications

• Active, unrestricted Registered Nurse (RN) license required
• Minimum of 3–5 years of experience in utilization management, clinical auditing, clinical compliance, or managed care
• Minimum of 2 years of clinical compliance auditing or healthcare auditing experience
• Strong knowledge of utilization management processes, clinical documentation, and regulatory compliance requirements
• Knowledge of Medicare, commercial managed care, and delegated services compliance requirements
• Strong analytical, critical thinking, and problem-solving skills
• Ability to work independently and exercise sound professional judgment
• Strong written and verbal communication skills
• Proficiency with Microsoft Office, including Excel, Word, and reporting tools
• Minimum of 3–5 years of experience in utilization management, clinical auditing, clinical compliance, or managed care.
• Minimum of 2 years of clinical compliance auditing or healthcare auditing experience.

Required skills

• Registered Nurse (RN) License, Clinical Compliance Auditing, Utilization Management, Clinical Documentation, Regulatory Compliance, Managed Care, Medicare Compliance, Delegated Services Compliance, Microsoft Office, Microsoft Excel, Microsoft Word

Preferred skills

• Written and Verbal Communication

Experience

• 3-5 years