Registered Nurse – 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.

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

• Conduct routine, scheduled, and ad hoc audits.

• Act as a secondary reviewer for denial documentation.

• Track audit findings to pinpoint trends, risks, and areas for improvement.

• Monitor clinical workflows and reporting processes for compliance risks, documentation shortcomings, and process deficiencies.

• Assist in developing audit tools, protocols, and compliance monitoring frameworks.

• Contribute to the development and upkeep of UM and PHM Plans and clinical compliance procedures.

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

• Aid leadership in pinpointing training needs and opportunities for clinical compliance enhancement.

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

• Analyze audit results and clinical data to discover trends, root causes, and improvement possibilities.

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

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

• Collaborate with Clinical Leadership, Compliance, and Operations teams to identify risks and bolster regulatory readiness.

• Utilize independent judgment to assess compliance risks and fortify the clinical compliance framework.

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

⛳️ Requirements

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

• Strong understanding 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 is required.

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

• Capability to work autonomously and exercise sound professional judgment.

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

• At least 2 years of experience in clinical compliance auditing or healthcare auditing is preferred as an additional qualification.

• Must provide a personal internet connection suitable for video calls and access to internal/external systems.

• Minimum internet speed of 100 Mbps download and 10 Mbps upload is required.

• Must be available during specified working hours.

• Required to participate in virtual meetings with cameras on.

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

🏝️ Benefits

• Fully remote work environment.

• All necessary work equipment provided at no cost.

• Comprehensive Medical, Dental, and Vision plans.

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

• Life and Disability insurance coverage.

• Options for Voluntary Life insurance.

• Employee Assistance Program (EAP) available.

• Paid time off programs.

• Paid parental leave benefits.

• Access to learning and development resources.

• Flexible work-from-home arrangements.

• Employees working 30 or more hours per week qualify for comprehensive benefits.