Registered Nurse, Clinical Compliance Auditor

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

📋 Description

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

• Oversee compliance with UM and PHM Plans, Managed Services Agreements, and specific contractual and regulatory obligations set by clients.

• Conduct routine, scheduled, and ad hoc audits as necessary.

• Act as a secondary reviewer for denial documentation.

• Track audit outcomes, clinical workflows, and reporting procedures to pinpoint trends, risks, documentation shortfalls, and gaps in processes.

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

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

• Assist leadership in recognizing training needs and opportunities for enhancing clinical compliance.

• Coordinate audit reviews, reporting processes, and compliance committee functions.

• Evaluate audit outcomes and clinical data to discover trends, root causes, and areas for improvement.

• Compile and deliver audit findings and compliance reports to clinical leadership and operational stakeholders.

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

• Adjust to changing business requirements and support cross-departmental initiatives.

⛳️ Requirements

• Valid and unrestricted Registered Nurse (RN) license is mandatory.

• In-depth understanding of utilization management processes, clinical documentation, and regulatory compliance standards.

• 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.

• Capability to work independently while exercising sound professional judgment.

• Proficiency in Microsoft Office applications, including Excel, Word, and various reporting tools.

• Preferred: at least 2 years of experience in clinical compliance auditing or healthcare auditing.

• Must provide an internet connection with a minimum of 100 Mbps download and 10 Mbps upload speeds.

• Required to be accessible during designated working hours and engage in virtual meetings with the camera on.

• Must adhere to security policies and procedures to safeguard PHI, PII, and Guidehealth intellectual property.

🏝️ Benefits

• Fully remote position with work-from-home flexibility.

• Comprehensive medical, dental, and vision insurance plans.

• 401(k) plan featuring a 3% employer match with a 6% employee contribution.

• Life and disability insurance coverage.

• Options for voluntary life insurance.

• Employee Assistance Program (EAP) available.

• Paid time off benefits.

• Paid parental leave offered.

• Access to learning and development resources.

• All necessary work equipment provided at no cost.

• Commitment to equal opportunity employment.