Medical Compliance Auditor - Managed Care

Position: Medical Compliance Auditor - Managed Care

Job ID: 152430

Location: US-TX-Bellaire

Department: Utilization Management

Talent Area: Registered Nurse

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8-5p

About Texas Children's Hospital

Texas Children’s Health Plan (TCHP) is the largest Texas Medicaid managed care organization, and is part of the Texas Children’s healthcare system. Founded in 1996, TCHP is the nation's first health maintenance organization (HMO) created just for children and pregnant women. Our plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area. Currently the Health Plan serves more than 450,000 members across three service areas (Harris, Jefferson, North East). Members of the plan receive care from our network of more than 4,000 primary care physicians, 8,000 specialists, and 110 hospitals. They can also receive care at The Center for Children and Women, a patient and family-centered medical home with two convenient locations for TCHP members who can have all their medical needs met in one place, receiving multiple services the same day. TCHP is a recognized leader at encouraging holistic care that empowers families to live healthier lives.   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. 


We are looking for someone with a nursing background, previous experience with managed care, and experience in auditing or utilization management. 


Think you’ve got what it takes?

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


  • 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

Apply Now
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