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Guide Healthcare
Guide Healthcare
51 – 200 Employees
HealthcareHealthcare InsuranceRecruitment
Guide Healthcare operates across allied health services and healthcare recruitment, with a focus on supporting and treating older adults. Established in 2018, the company works with clients, partners, and teams to deliver practical value in the healthcare sector while taking a different approach to service provision and recruitment. Its work may be relevant to professionals interested in healthcare, allied health, recruitment, and services for older people.
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Registered Nurse Clinical Compliance Auditor

Audit utilization management and clinical compliance for Guidehealth, a data-powered value-based healthcare company. Review documentation, regulatory adherence, and delegated services.

USUnited StatesPAPennsylvania
$82,000 – $87,000 / year
RemoteFull-timeMiddleSeniorEnglish RequiredAuditor

Description

  • Conduct clinical compliance audits of utilization management, denial documentation, clinical reporting, authorization compliance, and delegated services.
  • Check compliance with UM and PHM Plans, Managed Services Agreements, and client contractual and regulatory requirements.
  • Carry out routine, scheduled, and ad hoc audits.
  • Provide secondary review of denial documentation.
  • Track audit findings, clinical workflows, and reporting processes to identify trends, risks, documentation deficiencies, and process gaps.
  • Create and maintain audit tools, protocols, compliance monitoring frameworks, UM and PHM Plans, and clinical compliance procedures.
  • Mentor and advise Clinical Compliance Auditors and clinical operations staff, sharing subject matter expertise.
  • Help leadership identify training needs and opportunities to improve clinical compliance.
  • Coordinate audit reviews, reporting, and compliance committee activities.
  • Analyze audit results and clinical data to find trends, root causes, and opportunities for improvement.
  • Present audit findings and compliance reports to clinical leaders and operational stakeholders.
  • Help develop reporting tools, dashboards, and audit metrics.
  • Adjust to changing business needs and contribute to cross-functional initiatives.

Requirements

  • Hold an active, unrestricted Registered Nurse (RN) license.
  • Know utilization management processes, clinical documentation, and regulatory compliance requirements.
  • Have 3–5 years of experience in utilization management, clinical auditing, clinical compliance, or managed care.
  • Know Medicare, commercial managed care, and delegated services compliance requirements.
  • Work independently and exercise sound professional judgment.
  • Use Microsoft Office, including Excel, Word, and reporting tools proficiently.
  • Preferred: at least 2 years of clinical compliance or healthcare auditing experience.
  • Provide an internet connection with at least 100 Mbps download and 10 Mbps upload speeds.
  • Be available during stated working hours and attend virtual meetings with the camera on.
  • 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 when employees contribute 6%.
  • Life and disability insurance.
  • Optional life insurance coverage.
  • Employee Assistance Program (EAP).
  • Paid time off plans.
  • Paid parental leave.
  • Learning and development resources.
  • Necessary work equipment provided at no cost.
  • Equal opportunity employment.

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