Clinical Compliance Auditor

Guide Healthcare

. Conduct comprehensive clinical compliance audits covering utilization management, denial documentation, clinical reporting, authorization compliance, and delegated services requirements .

Posted 10/6/2026full-timeRemote • Texas • United StatesMid-LevelSenior💰 $82,000 - $87,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical compliance auditing, utilization management, and regulatory compliance, with a strong focus on analytical skills and effective communication. Proficient in developing audit tools and frameworks while providing mentorship and guidance to clinical operations staff.

Highest-signal resume keywords

Registered Nurse (RN) LicenseClinical Compliance AuditingUtilization Management ProcessesRegulatory Compliance RequirementsAnalytical and Problem-Solving Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AuditingUtilization ManagementClinical DocumentationAudit Tools DevelopmentCompliance Monitoring FrameworksData AnalysisReporting ProcessesTrend IdentificationDocumentation DeficienciesProcess Improvement

Soft Skills

MentorshipGuidanceCritical ThinkingIndependent WorkCommunication Skills

Tools & Technologies

Microsoft OfficeExcelReporting ToolsDashboards

Certifications & Qualifications

Registered Nurse (RN) License

Industry Keywords

Managed CareMedicare ComplianceDelegated Services ComplianceClinical ComplianceHealthcare Auditing

About the role

Key responsibilities & impact

Conduct comprehensive clinical compliance audits covering utilization management, denial documentation, clinical reporting, authorization compliance, and delegated services requirements
Monitor adherence to UM and PHM Plans, Managed Services Agreements, and client-specific contractual and regulatory requirements
Perform routine, scheduled, and ad hoc audits
Serve as a secondary reviewer for denial documentation
Monitor audit findings, clinical workflows, and reporting processes to identify trends, risks, documentation deficiencies, and process gaps
Develop and maintain audit tools, protocols, compliance monitoring frameworks, UM and PHM Plans, and clinical compliance procedures
Provide mentorship, guidance, and subject matter expertise to Clinical Compliance Auditors and clinical operations staff
Support leadership in identifying training needs and clinical compliance improvement opportunities
Facilitate audit reviews, reporting processes, and compliance committee support activities
Analyze audit results and clinical data to identify trends, root causes, and improvement opportunities
Prepare and present audit findings and compliance reports to clinical leadership and operational stakeholders
Support development of reporting tools, dashboards, and audit metrics
Adapt to evolving business needs and support cross-functional initiatives
Follow security policies and procedures to protect PHI, PII, and Guidehealth intellectual property

Requirements

What you’ll need

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
Ability to provide own internet connection with minimum 100 Mbps download and 10 Mbps upload
Ability to be accessible during stated working hours
Willingness to join virtual meetings with cameras on

Benefits

Comp & perks

Fully remote work arrangement
Necessary work equipment provided at no charge
Medical, Dental, and Vision plans
401(k) plan with a 3% employer match to a 6% contribution
Life and Disability insurance
Voluntary Life insurance options
Employee Assistance Program (EAP)
Paid time off plans
Paid parental leave
Learning and development resources
Flexible work-life balance
Comprehensive benefits package for eligible full-time employees working 30+ hours per week