Clinical Compliance Auditor - Remote

About the job

The 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.

• What 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.

WHO IS GUIDEHEALTH?
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients.