Job DescriptionThe Clinical Compliance Auditor II is responsible for ensuring Guidehealth's clinical operations, utilization management activities, and delegated services comply with regulatory requirements, client contractual obligations, and internal clinical standards. This role serves as a senior clinical compliance subject matter expert and performs advanced auditing, monitoring, and compliance validation activities to ensure adherence to Utilization Management (UM) and Population Health Management (PHM) Plans, Managed Services Agreements (MSAs), and value-based care program requirements.
In addition to conducting audits, this role provides leadership through mentorship, process improvement, audit program development, and cross-functional collaboration. The Clinical Compliance Auditor II partners closely with Clinical Leadership, Compliance, and Operations teams to identify risks, support regulatory readiness, and ensure clinical services meet the highest standards of accuracy, quality, and compliance.
This position operates with a high degree of autonomy, exercising independent judgment to evaluate compliance risks, support operational improvements, and strengthen Guidehealth's clinical compliance infrastructure.
As a growing and innovative organization, we operate with a high degree of agility. Employees are expected to adapt to evolving business needs, step in to support cross-functional initiatives, and contribute beyond traditional role boundaries when needed. This collaborative and flexible mindset is essential to our success. We encourage cross-training, ongoing development, and a commitment to learning across all areas of the business-ensuring we continue to grow as a high-performing, mission-driven team and you continue to grow and thrive as a member of our high-performing, mission-mission driven team.
What you'll be doing- Conducting comprehensive clinical compliance audits, including utilization management, denial documentation, clinical reporting, authorization compliance, and delegated services requirements.
- Monitoring adherence to UM and PHM Plans, Managed Services Agreements, and client-specific contractual and regulatory requirements.
- Performing routine, scheduled, and ad hoc audits to assess compliance with internal policies, regulatory standards, and client obligations.
- Serving as a secondary reviewer for denial documentation to ensure regulatory and contractual compliance.
- Monitoring audit findings to identify trends, risks, and opportunities for operational and compliance improvement.
- Monitoring clinical workflows and reporting processes to detect compliance risks, documentation deficiencies, or process gaps.
- Assisting in developing and maintaining audit tools, audit protocols, and compliance monitoring frameworks.
- Assisting in the development and maintenance of the UM and PHM Plans and clinical compliance procedures.
- Providing mentorship, guidance, and subject matter expertise to Clinical Compliance Auditors and clinical operations staff.
- Supporting leadership in identifying training needs and opportunities for clinical compliance improvement.
- Assisting in facilitating audit reviews, reporting processes, and compliance committee support activities.
- Analyzing audit results and clinical data to identify trends, root causes, and opportunities for operational and compliance improvement.
- Preparing and presenting audit findings and compliance reports to clinical leadership and operational stakeholders.
- Supporting the development of reporting tools, dashboards, and audit metrics to monitor compliance performance.
QualificationsWhat you'll need for success- 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.
What we'd love for you to have - Minimum of 2 years of clinical compliance auditing or healthcare auditing experience.
Additional InformationThe salary for this role is $82,000.00 to $87,000.00 per year based upon experience and skills.
BENEFITS:While you are hard at work advancing value-based healthcare, we are here to ensure YOU have the care you and your family need and the opportunities for growth and development. Our commitments to you include:
- Work from Home: Guidehealth is a fully remote company, providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs.
- Keep Health a Priority: We offer comprehensive Medical, Dental, and Vision plans to keep you covered.
- Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution.
- Have Peace of Mind: We provide Life and Disability insurance for those "just in case" moments. Additionally, we offer voluntary Life options to keep you and your loved ones protected.
- Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times.
- Take Time for Yourself: We offer paid time off plans helping you achieve work-life balance and meet your personal goals.
- Support Your New Family: Welcoming a new family member takes time and commitment. Guidehealth offers paid parental leave to give you the time you need.
- Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us.
All full-time employees of Guidehealth who work 30 hours per week or more are eligible for our comprehensive benefits package. Temporary employees and contractors are not eligible for benefits.
COMPENSATION:The listed compensation range listed is paid bi-weekly per our standard payroll practices. Final base pay decisions are dependent upon a variety of factors which may include, but are not limited to: skill set, years of relevant experience, education, location, and licensure/certifications.
REMOTE WORK TECHNICAL REQUIREMENTSGuidehealth is a fully remote company. We provide new employees with the necessary equipment to function in their role at no charge to the employee. Employees provide their own internet connection, capable of conducting video calls on camera and connecting to various internal and external systems. The required internet speed is a minimum of 100 mbps download, 10 mbps upload. Please run a speed test here to confirm your internet connection meets these requirements.
SECONDARY EMPLOYMENTAt Guidehealth, we value transparency and collaboration as part of our commitment to excellence. As your primary employer, we kindly ask all team members to disclose any secondary employment, regardless of whether it may present a potential conflict of interest.
To ensure smooth teamwork and availability, employees must be accessible during our stated working hours. We foster connection and engagement by asking team members to join virtual meetings with their cameras on.
Videos To Watchhttps://youtu.be/BAWs9H1UN2M?si=bQD-LaV4Cb6__UyO
