Medical Compliance Auditor - Health Plan

Position: Medical Compliance Auditor - Health Plan

Job ID: 156935

Location: US-TX-Bellaire

Department: Controls & Compliance

Talent Area: Registered Nurse

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p

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 14,000+ dedicated team members, visit for career opportunities. You can also learn more about our amazing culture at   Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.


We are searching for a Medical Compliance Auditor -- someone who works well in a fast-paced setting. In this position, you will review and approve or deny medical claim appeals and perform clinical audits of medical records submitted in support of services billed by providers. This process includes 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 :

  • Assess the treatment plan, clinical information, and medical necessity of all requested services
  • Researches Medicaid/CHIP Program requirements, benefits, CPT coding guidance and any other industry standard guidelines that will assist in performing the clinical review of the medical claim appeal
  • 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
  • Expeditiously communicates essential information to providers to facilitate claims payment and works with Provider Relations staff to on an as needed basis
  • Perform Clinical Review and make recommendation on Audit Pass/Fail
  • Identifies potential quality of care issues documents in the electronic file, and discusses with SIU team
  • Works closely with SIU team to review policies and procedures and SIU program documents to ensure documents are kept up to date with regulatory requirements


  • Bachelor’s degree in nursing required
  • RN license from the Texas Board of Nursing or Nursing Licensure Compact required
  • 2 years RN, medical auditing, and/or managed care experience required

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