Clinical Compliance Auditor - Remote

📋 Description

• Conducting comprehensive clinical compliance audits, including utilization management, denial
• Monitoring adherence to UM and PHM Plans, Managed Services Agreements, and client-specific
• Performing routine, scheduled, and ad hoc audits to assess compliance with internal policies
• Serving as a secondary reviewer for denial documentation to ensure regulatory and contractual
• Monitoring audit findings to identify trends, risks, and opportunities for operational and
• Monitoring clinical workflows and reporting processes to detect compliance risks, documentation

🎯 Requirements

• Active, unrestricted Registered Nurse (RN) license required.
• Strong knowledge of utilization management processes, clinical documentation, and regulatory
• Minimum of 3–5 years of experience in utilization management, clinical auditing, clinical
• 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.

🎁 Benefits

• Work from Home: Guidehealth is a fully remote company, providing you the flexibility to spend less
• Keep Health a Priority: We offer comprehensive Medical, Dental, and Vision plans to keep you
• 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.
• Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you
• Take Time for Yourself: We offer paid time off plans helping you achieve work-life balance and meet