Clinical Compliance Auditor

This is a fully remote position, open to applicants in Texas.

📋 Description

• Execute thorough clinical compliance audits encompassing utilization management, denial documentation, clinical reporting, authorization compliance, and delegated services requirements.

• Oversee adherence to UM and PHM Plans, Managed Services Agreements, as well as client-specific contractual and regulatory obligations.

• Carry out routine, scheduled, and ad hoc audits.

• Act as a secondary reviewer for denial documentation.

• Monitor audit findings, clinical workflows, and reporting processes to detect trends, risks, documentation deficiencies, and process gaps.

• Create and sustain audit tools, protocols, compliance monitoring frameworks, UM and PHM Plans, and clinical compliance procedures.

• Offer mentorship, guidance, and subject matter expertise to Clinical Compliance Auditors and clinical operations personnel.

• Assist leadership with training requirements and opportunities for clinical compliance enhancement.

• Facilitate audit reviews, reporting processes, and compliance committee support activities.

• Analyze audit results and clinical data to uncover trends and root causes.

• Prepare and present audit findings and compliance reports to clinical leadership and operational stakeholders.

• Aid in the development of reporting tools, dashboards, and audit metrics.

• Adapt to changing business needs and support cross-functional initiatives.

⛳️ Requirements

• Active, unrestricted Registered Nurse (RN) license is mandatory.

• Extensive knowledge of utilization management processes, clinical documentation, and regulatory compliance standards.

• A minimum of 3–5 years of experience in utilization management, clinical auditing, clinical compliance, or managed care.

• Familiarity with Medicare, Commercial Managed Care, and compliance requirements for delegated services.

• Ability to work autonomously and apply sound professional judgment.

• Proficient in Microsoft Office, including Excel, Word, and reporting tools.

• Preferred minimum of 2 years of experience in clinical compliance auditing or healthcare auditing.

• Capable of providing and maintaining a required internet connection of at least 100 Mbps download and 10 Mbps upload.

• Must be available during specified working hours.

• Must adhere to security policies and procedures safeguarding PHI, PII, and company intellectual property.

🏝️ Benefits

• 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 a 6% employee contribution.

• Life and Disability insurance.

• Voluntary Life options available.

• Employee Assistance Program (EAP).

• Paid time off plans.

• Paid parental leave.

• Learning and development resources.

• Flexible work arrangement.

• Employees must provide their own internet connection; a minimum of 100 Mbps download and 10 Mbps upload is required.