Clinical Compliance Auditor

Guide Healthcare

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

Posted 10/7/2026full-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 processes, and regulatory compliance requirements, with a strong ability to analyze data and present findings effectively. Proficient in developing audit tools and providing mentorship to clinical operations staff.

Highest-signal resume keywords

Registered Nurse (RN) LicenseUtilization Management ProcessesClinical Compliance AuditingMicrosoft Office ProficiencyMedicare Compliance Knowledge

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Compliance AuditingUtilization ManagementRegulatory ComplianceClinical DocumentationAudit Tools DevelopmentData AnalysisReporting ProcessesTrend IdentificationProcess ImprovementRisk Assessment

Soft Skills

MentorshipProfessional JudgmentIndependent WorkCommunicationCollaboration

Tools & Technologies

Microsoft ExcelMicrosoft WordReporting ToolsDashboardsAudit Metrics

Certifications & Qualifications

Registered Nurse (RN) License

Industry Keywords

Clinical ComplianceManaged CareMedicareCommercial Managed CarePHI ProtectionPII Protection

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 with 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 and root causes
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

Requirements

What you’ll need

Active, unrestricted Registered Nurse (RN) license required
Strong knowledge of utilization management processes, clinical documentation, and regulatory compliance requirements
Minimum of 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
Ability to work independently and exercise sound professional judgment
Proficiency with Microsoft Office, including Excel, Word, and reporting tools
Minimum of 2 years of clinical compliance auditing or healthcare auditing experience preferred
Ability to provide and maintain required internet connection of at least 100 Mbps download and 10 Mbps upload
Must be accessible during stated working hours
Must follow security policies and procedures protecting PHI, PII, and company intellectual property

Benefits

Comp & perks

Fully remote work arrangement
Necessary work equipment provided at no charge
Comprehensive Medical, Dental, and Vision plans
401(k) plan with a 3% employer match to 6% employee contribution
Life and Disability insurance
Voluntary Life options
Employee Assistance Program (EAP)
Paid time off plans
Paid parental leave
Learning and development resources
Flexible work arrangement
Employees provide their own internet connection; minimum 100 Mbps download and 10 Mbps upload required