Medical Compliance Auditor

Texas Children's Medical Center · Bellaire, TX Full Time

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Job Description

Description 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? Job Duties & Responsibilities • Assess the treatment plan, clinical information, and medical necessity of all requested services • Utilizes established criteria to appropriately review billed services within established timeframe required. • Consults with medical directors and clinical staff regarding patient’s history and current care needs and whether services billed were appropriate. • Refers case failing medical necessity criteria to the Special Investigations Unit (SIU) Director and SIU Workgroup for review and a recommendation for action. • Telephonic follow-up with the provider’s office to request additional information as needed. • Completes timely entry of information into electronic file including a chart with detailed findings of the review and a report summarizing the results of the audit. • Evaluate benefit coverage and regulatory guidelines pertinent to decision making for each investigation. • Perform Clinical and Coding Review on Medical Claim Appeals. • Assess and process all education and recoupment letters after Special Investigative Committee review decision. • Facilitates provider communication and education. • Liaisons with internal staff members. • Perform Clinical Review and make recommendation on Audit Pass/Fail. • Ongoing assessment for quality indicators and concerns. Skills & Requirements • Required Associate's Degree in Nursing or • Technical Diploma in Vocation Nursing • Preferred Bachelor’s Degree in Nursing • Required LVN - Lic- Licensed Vocational Nurses Texas Board of Nursing or Nursing Licensure Compact or • RN-Lic-Registered Nurses Texas Board of Nursing or Nursing Licensure Compact • Preferred CPC-Cert-Cert Professional Coder Americal Academy of Professional Coders • Required 3 years Clinical experience in the applicable field according to the license (LVN or RN) • 4 years of Medical Auditing experience.

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What Most Job Listings Don’t Tell You

General overview for this role type — specific duties and requirements vary by employer.

Support roles in senior living — housekeeping, maintenance, activities, and social work — are far more resident-facing than similar positions in other industries. Housekeepers and maintenance staff interact with residents in their personal living spaces daily, which requires discretion, patience, and genuine respect for the people who live there. In Texas, even non-clinical staff must complete facility-specific training on topics like abuse prevention, infection control, and emergency procedures.

Activities coordinators and social workers play a direct role in resident well-being — isolation and depression are significant concerns in senior living, and programming that keeps residents socially engaged has measurable health outcomes. Maintenance staff in senior care need to understand life-safety systems (fire alarms, emergency generators, call systems) and are often the first responders for building emergencies. Background checks are required for all positions, and many facilities prefer candidates who have previous experience working with older adults.

What to Expect in This Role Day-to-Day

Based on typical senior living facilities in the Houston area.

For housekeeping roles, the day follows a room-by-room schedule — cleaning resident rooms, sanitizing common areas, managing laundry, and responding to spill or accident cleanups as they happen. Infection control protocols are more rigorous than in hotels or commercial cleaning, especially during flu season or respiratory illness outbreaks.

Maintenance staff handle a daily work order queue — everything from changing light bulbs and fixing call buttons to HVAC maintenance and plumbing repairs. Life-safety equipment checks (fire extinguishers, exit lighting, generator testing) happen on set schedules. Activities professionals plan and lead group programming — exercise classes, crafts, music sessions, outings — and also provide one-on-one engagement for residents who cannot participate in group settings. Social workers manage care conferences, discharge planning, family mediation, and community resource referrals. Across all these roles, the common thread is that you become a familiar, trusted presence in residents' daily lives.

Houston Area Salary Data

According to the Bureau of Labor Statistics, Home Health and Personal Care Aide positions in the Houston metro area earn a median wage of $10.97/hr ($22,818/yr). The typical range is $10.60 – $13.28/hr (25th–75th percentile).

Entry Level (10th) $20,613/yr

Houston Median $22,818/yr

Experienced (90th) $30,597/yr

vs. National Median -34.6%

Source: Bureau of Labor Statistics, Occupational Employment & Wage Statistics (Houston-Pasadena-The Woodlands, TX Metro Area). Salary data provided by Houston Senior Living Guide.