Medical Compliance Auditor - The Health Plan

Position: Medical Compliance Auditor - The Health Plan

Job ID: 146171

Location: US-TX-Bellaire

Department: Controls & Compliance

Talent Area: Registered Nurse

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a -5p Monday - Friday

About Texas Children's Hospital

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.   To join our community of 13,000 dedicated team members, visit for career opportunities. You can also learn more about our amazing culture at  


We are searching for a Medical Compliance Auditor – someone who works well in a fast-paced managed care setting. In this position, you’ll review and approve or deny medical claim appeals and perform clinical audits of medical records submitted in support of services billed by providers. You must have the ability to have clinical judgment, utilization review, application of product benefits, understanding of regulatory requirements for Medicaid managed care and fraud and abuse, and verification of medical necessity utilizing nationally recognized criteria.

Think you’ve got what it takes?

Responsibilities :

Job Duties & Responsibilities


  • Assess the treatment plan, clinical information, and medical necessity of all requested services
  • Perform Clinical and Coding Review on Medical Claim Appeals
  • Assess and process all education and recoupment letters after Special Investigative Committee review decision
  • Notifies providers of denied services through written correspondence with education attached and follows up with provider verbally if requested by the provider
  • Collaborates with all disciplines within the health plan to meet goals and objectives.
  • Perform Clinical Review and make recommendation on Audit Pass/Fail
  • Ongoing assessment for quality indicators and concerns
  • Identifies potential quality of care issues documents in the electronic file, and discusses with SIU team
  • Quality issues may be referred to the Quality Department for further follow up


Skills & Requirements


  • 2 years of RN, medical auditing, and/or managed care experience
  • RN - Lic-Registered Nurses by Texas State Board of Nursing
  • Bachelor's Degree in Nursing
  • At least two years of managed care expertise, and/or utilization review experience
  • Highly motivated and able to work independently
  • Must be a team player that is able to effectively collaborate with team members and outside departments
  • Knowledge of pediatrics is a plus
  • Excellent verbal and written skills, good computer skills (Microsoft word and excel), and excellent clinical judgment and reasoning skills

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