291 clinical review auditor jobs found

The Diagnostic Related Groups (DRG) Clinical Auditor will be responsible for performing DRG validation (clinical/coding) reviews of medical records and/or other documentation. This role will determine correct DRG/coding as defined by review methodologies specific to the type of review. This involves completing medical record reviews, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination. This role will utilize their experience with ICD-10-CM & PCS coding guidelines, the ability to understand modern pharmacology, disease management and clinical intervention procedures. The ideal DRG Clinical Auditor candidate has strong written and verbal communication skills, clinical knowledge of disease processes, and knowledge of medical necessity rules.   ESSENTIAL FUNCTIONS & RESPONSIBILITIES: The Clinical Auditor will review medical records to determine accuracy of billing through verification of coding and...

CERiS in Fort Worth, Texas is seeking a DRG Quality Control/Clinical Auditor. The Diagnostic Related Groups (DRG) QC Clinical Auditor will be responsible for performing quality control DRG validation (clinical/coding) reviews of internal audit team reviews of medical records and/or other documentation to determine correct DRG/coding that is clinically supported as defined by review methodologies specific to the contract for which review services are being provided. This involves completing medical records review, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination, as well as communicating missed or incorrect information to the auditors in a professional manner. Experience using, ICD-10-CM & PCS coding guidelines, the ability to understand modern pharmacology, disease management and clinical intervention procedures. This is a remote position. Job Duties and Responsibilities: The Quality Control...

The Quality Assurance Nurse is responsible for case management quality assurance and mentorship of operations staff, providing tools and calibrating processes, while ensuring consistent delivery of CorVel’s case management services. This is a remote position. ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Develop, implement, and provide ongoing quality assurance calibration of processes as well as a case management mentoring, both managed and delivered at the operational level Educate and equip operations with performance measurement and reporting tools that can be used to objectively measure and grow operations Provide national account and regulatory quality oversight As applicable, provide oversight and management of URAC compliance and renewals Work with executive, general and case management department management to ensure the case management department successfully implemented and is adhering to CorVel standards (including quality assurance, reporting, and...

The hospital bill audit nurse supervisor will maintain a positive team building approach with emphasis on overseeing the day to day functions of hospital bill audit nurses, reporting, leadership and professional communication with all CERiS departments.  This is a remote position. ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Utilize nursing education, experience and industry best practices to lead a team of registered nurses to plan, execute and deliver timely and accurate hospital bill audits Ensure accuracy of audits through acquired knowledge of client policies, provider contract information, and other standard guidelines Assist in the development and support of auditors to meet and exceed productivity requirements based on CERiS productivity standards Act as a point of contact to answer and resolve auditor issues with the goal of providing excellent customer service and relationship management  Perform audits as necessary Keep manager informed of any issues...

Job Description At WSFS Bank, we empower our Associates to grow their careers, guide our customers to secure their financial futures, and actively support our Communities so they can fully thrive. Careers with WSFS Bank offer an inclusive and supportive culture, competitive salaries, advancement opportunities, and more. We are the region's locally headquartered bank and wealth management company. We are honored to consistently be named a Top Workplace by our Associates, who make a difference every day for the people, businesses, and Communities we serve. We Stand For Service® is more than part of our name, it’s our mission and our purpose. WSFS Bank is currently seeking a Quality Control Specialist. The Quality Control Specialist will act as gatekeeper to ensure that the highest quality standards are maintained throughout the Residential Mortgage and Retail New loan and Modifications processes and ongoing portfolio reviews. Job Responsibilities: Perform post-closing...

At EMC, we’re all about working together to make an impact. As part of our team, you’ll have the opportunity to grow, contribute, and gain experience that matters. We strive to be caring leaders, close partners, and responsive experts—always supporting each other to do our best work. Join us, and let’s improve lives together.    Essential Functions:   Manages a team responsible for accurate and timely reporting to regulatory authorities and reporting bureaus. Leads the analysis of regulatory texts, official guidance documents, regulatory updates, and industry publications to understand the nuances of reporting requirements. Maintains a deep understanding of the regulations and reporting requirements impacting assigned lines of business. Collaborates closely with Compliance, legal counsel, and regulatory affairs teams to ensure a comprehensive understanding of regulatory requirements. Oversees risk assessments and impact analyses to evaluate the potential...

Description This a range posting. Candidates will be considered for the appropriate level depending upon experience and qualifications.   The Business Operations Lead / Manager for Risk Financing is responsible for strengthening the operational backbone of the Risk Financing function to execute on our vision. This role owns Standard Operating Procedures (SOPs), drives process optimization and innovation, reduces operational waste, whilst being aware of impact on other functions & teams.   The role combines operational leadership with strong reinsurance knowledge and data fluency, using insights to improve efficiency, transparency, and decision‑making across the end‑to‑end reinsurance lifecycle.   Job Responsibilities Operational Excellence & SOP Ownership Own, maintain, and continuously improve Risk Financing Standard Operating Procedures across the treaty lifecycle Fully document Risk Financing processes including leadership...

Why USAA? At USAA, our mission is to empower our members to achieve financial security through highly competitive products, exceptional service and trusted advice. We seek to be the #1 choice for the military community and their families. Embrace a fulfilling career at USAA, where our core values – honesty, integrity, loyalty and service – define how we treat each other and our members. Be part of what truly makes us special and impactful. We are proud to support active-duty military spouses. USAA roles may offer remote or hybrid flexibility for active-duty military spouses consistent with applicable policy and business needs. The Opportunity As a dedicated Senior Audit Manager you’ll manage audit engagements, varying in complexity, and participate in complex, cross-functional risk-based assurance and advisory engagements driving quality of audit work. May lead engagements as Auditor-In-Charge (AIC). Maintains knowledge of financial services regulations and...

Why USAA? At USAA, our mission is to empower our members to achieve financial security through highly competitive products, exceptional service and trusted advice. We seek to be the #1 choice for the military community and their families. Embrace a fulfilling career at USAA, where our core values – honesty, integrity, loyalty and service – define how we treat each other and our members. Be part of what truly makes us special and impactful. We are proud to support active-duty military spouses. USAA roles may offer remote or hybrid flexibility for active-duty military spouses consistent with applicable policy and business needs. The Opportunity We are seeking a Risk and Compliance Advisor Lead – Information Security to provide second-line independent oversight and effective challenge across business products, services, and processes. This role is responsible for ensuring alignment with regulatory requirements and USAA policies and procedures while strengthening the...

Why USAA? At USAA, our mission is to empower our members to achieve financial security through highly competitive products, exceptional service and trusted advice. We seek to be the #1 choice for the military community and their families. Embrace a fulfilling career at USAA, where our core values – honesty, integrity, loyalty and service – define how we treat each other and our members. Be part of what truly makes us special and impactful. We are proud to support active-duty military spouses. USAA roles may offer remote or hybrid flexibility for active-duty military spouses consistent with applicable policy and business needs. The Opportunity We are proud to support active-duty military spouses. USAA roles may offer remote or hybrid flexibility for active-duty military spouses consistent with applicable policy and business needs. As a dedicated Director, Quality Assurance , you will lead a team responsible for developing, implementing, and governing...

Are You Driven?® We Are. We are a company of driven, enthusiastic and determined people. We celebrate achievement and success.  We foster innovation, determination and recognition. Because of that, our employees feel recognized and rewarded for the contributions they make on a daily basis. At GAINSCO, it is our people that set us apart. If you are looking for a place where you can make a difference, perceive how your work impacts the company, and be recognized for your efforts and passion, then GAINSCO is the company for you. Why Join GAINSCO? GAINSCO’s work environment rewards engaged individuals who have a desire to contribute and succeed. That’s because our culture encourages individuals to grow their skills as they build their careers. Come join us and become a champion with GAINSCO. As a Claims Manager, Liability to lead a team of Team Leaders and oversee intermediate complexity coverage and liability investigations. This role combines leadership, operational...

If you’re passionate about being part of a dynamic organization that enables a Fortune 100 company with nearly $70 billion in annual sales to drive innovation and adopt new technologies that deliver business results, then Nationwide’s Technology team could be the place for you! At Nationwide®, “on your side” goes beyond just words. Our customers are at the center of everything we do and we’re looking for associates who are passionate about delivering extraordinary care. Position Summary: The Mission Critical Project Coordinator is responsible for overseeing the daily operations, maintenance, and reliability of critical infrastructure systems in the facility. This role leads a team of technicians and contractors in maintaining uninterrupted operation of electrical, mechanical, HVAC, network cabling and backup power systems that support 24/7 mission-critical operations. This position ensures all maintenance activities are performed safely, efficiently, and in compliance with...

Together we fight for everyone’s opportunity for a better financial future. We will do this together — with customers, partners and colleagues. We will fight for others, not against: We will stand up for and champion everyone’s access to opportunities. The status quo is not good enough … we believe every individual and every community deserves access to financial opportunities. We are determined to support both individuals and communities in reaching a better financial future.  We know that reaching this future depends on our actions today. Like our Purpose Statement, Voya believes in being bold and committed to action.  We are committed to a work environment where the differences that we are born with — and those we acquire throughout our lives — are understood, valued and intentionally pursued. We believe that our employees own our culture and have a responsibility to foster an environment where we all feel comfortable bringing our whole selves to work. Purposefully...

We are actively seeking a proactive, creative Senior Software Engineer who will be responsible for architectural design and implementation of Guardian's next-generation web self-service platforms APIs using .Net Core, C#. You will: Design, develop, and deploy high-volume, high-usage self-service web portals and APIs, utilizing .Net Core, C#, React, Next.js, and responsive CSS. Collaborate with Technical Teams, Technical Manager, Project Manager and subject matter experts from businesses and work closely with SMEs to understand, plan and implement. Ensure compliance with security, privacy, legal, infrastructure, and administrative/corporate processes and policies. Lead code reviews and administer paired programming. Provide unique insight into the analysis of customer business requirements that may cross multiple functional areas and/or multiple technical platforms and understand the broad strategic implications. Act independently and as part of a team to...

Job Title Digital Workplace AV Support Engineer Location Bethlehem, PA. This role requires travel to other Guardian locations including Hudson Yards (NYC), Holmdel, NJ, and additional sites as needed (up to 25%). Occasional off-hours and weekend support is required. Job Summary Guardian is seeking a highly capable AV Support Engineer to join the Digital Workplace organization. This role is responsible for delivering reliable, high-touch audiovisual and collaboration support across conference rooms, executive meeting spaces, and enterprise event environments. This is a hands-on, customer-facing role supporting Microsoft Teams Rooms and modern hybrid collaboration technologies. The position requires strong technical depth, composure under pressure, and the ability to resolve issues in real time during business-critical meetings and events. The ideal candidate operates independently, partners effectively across IT, Facilities, and vendors, and takes ownership of...

The Payment Integrity Analyst is responsible for accurately reviewing and completing pre- and post pay claim audits based on client, policy, industry standards and/or CMS guidelines.   ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Reviews, analyzes, and completes internal audits and/or appeals in accordance with client policy, CMS guidelines and industry standards in clear and professional written communication Use clinical judgement to appropriately interpret and apply client policies along with CMS guidelines as it relates to reviews done by CERIS such as itemized bill, DRG and/or specialty audits Utilize applicable tools and resources to complete internal audits and/or appeals Timely completion of internal audits and/or appeals Attends clinical team meetings, company meetings, educational opportunities/trainings, and other meetings Additional duties as assigned   KNOWLEDGE & SKILLS: Ability to use clinical judgment and analytical skills for...

Why USAA? At USAA, our mission is to empower our members to achieve financial security through highly competitive products, exceptional service and trusted advice. We seek to be the #1 choice for the military community and their families. Embrace a fulfilling career at USAA, where our core values – honesty, integrity, loyalty and service – define how we treat each other and our members. Be part of what truly makes us special and impactful. We are proud to support active-duty military spouses. USAA roles may offer remote or hybrid flexibility for active-duty military spouses consistent with applicable policy and business needs. The Opportunity This role provides strategic leadership for Auto Physical Damage (APD), overseeing both repairable and total loss claims. The Experience Owner Lead is accountable for end-to-end process optimization, including estimating practices, repair cost and accuracy, total loss valuation, title procurement, and salvage inventory...

Are You Driven?® We Are. We are a company of driven, enthusiastic, and determined people. We celebrate achievement and success.  We foster innovation, determination, and recognition. Because of that, our employees feel recognized and rewarded for the contributions they make daily. At GAINSCO, it is our people that set us apart. If you are looking for a place where you can make a difference, understand how your work impacts the company, and be recognized for your efforts and passion, then GAINSCO is the company for you. Why Join GAINSCO? GAINSCO’s work environment rewards engaged individuals who have a desire to contribute and succeed. That’s because our culture encourages individuals to grow their skills as they build their careers. Come join us and become a Champion with GAINSCO. We are seeking a dedicated and experienced professional to join our team as a Claims Team Leader. In this role, you’ll lead a team of Claims Representatives who handle low to...

If you're passionate about being part of a diverse organization that enables a Fortune 100 company with nearly $70 billion in annual sales to deliver innovative business solutions with excellence, then Nationwide's Legal team could be the place for you! At Nationwide®, “on your side” goes beyond just words. Our customers are at the center of everything we do and we’re looking for associates who are passionate about delivering extraordinary care. This position is a critical member of Nationwide’s Alternative Risk, Reinsurance, and Insurance Claims legal center of excellence within the Office of the Chief Legal Officer (OCLO), supporting complex matters across the Nationwide enterprise. The role provides specialized legal and regulatory counsel on alternative risk financing strategies, reinsurance transactions, and insurance and reinsurance claims, including related coverage, regulatory, governance, and external audit matters for Property & Casualty and Financial Services...

Software Engineer – Java Description As a Software Engineer, you will develop and execute key technology components of the Group Benefits Absence Platform. Absence Comprehensive Experience (ACE) is one of the key initiatives that will drive the success of the Group Benefits growth strategy.  It is one of the largest programs within Guardian today.  This is not just a multi-year program to re-platform; it is the future of how we transform as a business: bringing a comprehensive Disability and Absence Management suite of offerings to Guardian Insurance customers.  This role will work directly with solution architects, testing partners, cross-functional stakeholders and development team members to define, design and deliver the technical solutions that will support the business’ vision, strategy and goals.  The role will specifically support the objectives aligned with the ACE Program, implementing absence functionality across multiple workstreams. You are A...