Job Description:

• 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 in identifying training and clinical compliance improvement opportunities
• Facilitate audit reviews, reporting processes, and compliance committee activities
• Analyze audit results and clinical data to identify trends, root causes, and improvement opportunities
• 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:

• Active, unrestricted Registered Nurse (RN) license required
• Strong knowledge of utilization management processes, clinical documentation, and regulatory compliance requirements
• 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
• Preferred: minimum of 2 years of clinical compliance auditing or healthcare auditing experience
• Ability to provide an internet connection with at least 100 Mbps download and 10 Mbps upload
• Ability to be accessible during stated working hours and participate in virtual meetings with camera on
• Must follow security policies and procedures to protect PHI, PII, and Guidehealth intellectual property

Benefits:

• Fully remote work with work-from-home flexibility
• Medical, dental, and vision plans
• 401(k) plan with a 3% employer match to a 6% employee contribution
• Life and disability insurance
• Voluntary life insurance options
• Employee Assistance Program (EAP)
• Paid time off plans
• Paid parental leave
• Learning and development resources
• Necessary work equipment provided at no charge
• Equal opportunity employment