314 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...

About Us  We’re not like other insurance companies. From our specialty products to our business model, our culture to our results — we’re different. Different is who we are, and how we work, interact, deliver and succeed together. Creating a different and better insurance experience doesn’t just happen. It takes focus and a shared passion for going beyond the expected to forge relationships and deliver care that makes a difference. This approach rises from and is supported by our talented, ethical and smart team of employee owners united around a single purpose: to work alongside our customers and partners when they need us, in unexpected ways, with exceptional results. Apply today to make a difference with us.  RLI is a Glassdoor Best Places to Work company with a strong, successful background. For decades, our financial track record has been stellar — a testament to our culture and validation of our reputation as an excellent underwriting company....

Overview AmTrust Financial Services, a fast growing commercial insurance company, has a need for a Telephonic Medical Case Manager, RN.   PRIMARY PURPOSE:  To provide comprehensive quality telephonic case management to proactively drive a medically appropriate return to work through engagement with the injured employee, provider and employer.  Our nurses will be empathetic informative medical resources for our injured employees and they will partner with our adjusters to develop a personalized holistic approach for each claim.  These responsibilities may include utilization review, pharmacy oversight and care coordination.    This position is remote with a preference of working hybrid out of one of our AmTrust office locations! Responsibilities Uses clinical/nursing skills to determine whether all aspects of a patient’s care, at every level, are medically necessary and appropriately delivered. Perform...

Job Type: Full time   Exempt/Non Exempt:   Salary Job Description:   Location Details: Remote Location. Position Schedule / Shift: Monday to Friday, 8:00am – 5:00pm Position Summary: Serves as a team leader/senior technical team member in the planning, designing, developing, implementing, and/or supporting complex to moderately complex new or revised processes, systems, or networks.  Acts as an acknowledged expert in one or more technical specialties and/or mission critical application systems, and provides leadership in design, development and application integration.  Ensures functional and technical designs support customer requirements.  Develops an understanding of the Auto Club Group business strategy and competitive environment and translate and implements business strategies into technology solutions.  Provides a high degree of technical and/or application expertise and design/programming leadership.  Assists Security team in the...

Job Description: Title: Billing Specialist – Shared Services   Remote:  candidates in Florida | Supporting:  Shared Services Seeking:  2 years of billing and account support experience, EPIC experience strongly preferred   Please note: If this position is posted as either fully remote and/or hybrid, in accordance with company policy, individuals residing within a 50-mile radius of a branch location may be required to work onsite in a hybrid capacity as there may be occasions when on-site presence is necessary to meet specific business needs. Additionally, our remote work policy includes having a dedicated, distraction-free workspace. Remote work is not a substitute for childcare, elder care, or other personal responsibilities during working hours. To view our branch locations, please visit: ioausa.com/locations    About the Role:  The Billing Specialist is responsible for processing Agency Bill transactions, including premiums, taxes, fees, installments, and...

Description Summary: The IT Risk Director, Resiliency & Business Continuity is responsible for leading the First Line Resiliency and Business Continuity Program across assigned business segments. This role establishes the strategic vision, governance, and execution framework for resiliency capabilities that enable the organization to prepare for, respond to, recover from, and adapt to operational disruptions. The IT Risk Director provides leadership, effective challenge, and partnership to business leaders, risk partners, technology teams, and support functions to ensure resilience risks are identified, assessed, mitigated, and monitored in alignment with enterprise standards and regulatory expectations. Duties and Responsibilities: Provide independent review and challenge of business continuity and resiliency activities performed by business units. Facilitate completion of Business Impact Analyses,...

The Role: WTW is looking for an energetic individual with experience/expertise in activities relating to growth, pharmacy benefit management, growth, clinical pharmacy, and/or client facing roles to join our growing mid-market (MM) pharmacy team. As a MM-focused Pharmacy Consultant, you will be at the forefront of managing pharmacy benefits projects for clients and leveraging your experience as a pharmacy benefits expert to make recommendations on plan design and management. You will participate in new business activities and the creation of new intellectual capital.   You will position yourself to grow into a senior relationship management and/or leadership role by serving as the subject matter expert on pharmacy projects and working alongside industry experts on cutting-edge solutions. The ideal candidate is a client-centric problem solver who possesses the ability to balance member experience, financial considerations, client clinical/program needs and business growth. You...

Position Title Product Security Principal   Location New York, NY 10018   Job Summary Serves as the embedded security subject matter expert and thought lead for assigned product lines within the product operating model framework. Partners with the Technology Line of Business Lead, Business Architect, and Business Unit Risk Manager (BURM) to cultivate a security-first culture, ensuring products are secure from design through deployment. This position is accountable for application-specific security controls, threat modeling, security architecture reviews, secure code practices, and security testing coordination. Responsible for identifying and managing security risks, translating regulatory and policy requirements into actionable control designs, and serving as the clear point of escalation for IT Risk and Cyber domains within the product. Acts with urgency to monitor Key Risk Indicators, manage emerging security issues, and drive real risk reduction outcomes across the...

By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve. Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies Certified as a Great Place to Work® Fortune Best Workplaces in Financial Services & Insurance Disability Representative Disability Representative Our teams thrive together! We collaborate in person and embrace a flexible hybrid work style. To join us, you’ll need to live near our Dynamic Center of Excellence West Hills, CA. 8521 Fallbrook Ave. Suite 250, West Hills, CA ✨ What we offer: A stable, consistent work environment —both in-office and virtual A comprehensive training program to help you support employees and customers...

Senior Manager, Reinsurance Accounting Wilton, CT or Parsippany, NJ The Manager, Reinsurance Accounting, is a key member of AIG’s Reinsurance Controllership team ensuring accurate accounting, robust internal controls and timely financial reporting for AIG’s domestic Commercial and Personal insurance businesses.  Reporting to the Director, External Reinsurance, this role is primarily responsible for managing the financial and operational controlling activities associated with multiple complex external reinsurance programs.  Given the level of complexity across these programs, this role is structured with three direct reports and an extensive offshore platform. Success in this role will require a strong and well-balanced combination of re/insurance technical knowledge, operational savvy with an ability to efficiently leverage all levels of available resources, connecting operational inputs and outcomes to the financial results of AIG, organizational dexterity with capability...

Description Vice President, Loan Admin Oversight & Partnerships Team: Loan Operations · Operational Strategy & Delivery Location: Boston, MA or New York, NY   About the Role Liberty Mutual Investments (LMI) is seeking a detail-oriented and relationship-driven operations professional to join our growing Loan Operations team as Vice President, Loan Admin Oversight & Partnerships. This is a senior, high-impact role and a key addition to a newly formed function being purpose-built to support the continued growth and build-out of a best-in-class loan operations platform.   This VP will serve as the primary owner of LMI's loan administration relationships and the operational integrity of the loan book of record. The role is responsible for overseeing day-to-day loan administration performance, managing vendor and collaborator partnerships, and ensuring cross-system alignment across LMI's multi-platform loan operations environment. This role...

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 highly skilled Compliance and Operational Risk Testing Analyst Senior – Information Security and Corporate Functions     to join our team. This role is responsible for executing and enhancing technology-focused risk and compliance testing programs to ensure a strong and effective control environment across the...

As a team member in Finance at Nationwide, a Fortune 100 company with nearly $70 billion in annual sales, the opportunities are endless! Let Nationwide help create your career journey! 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. Job Description This role provides portfolio oversight for the E&S/S Programs Planning Unit. Responsibilities include: Lead program-level profitability reviews and recommend actions on rate, non-rate, mix, and reinsurance. Own core pricing assumptions and methodologies for assigned programs, aligned to Reserving, Planning, and target CR / PLR. Build and maintain pricing and monitoring tools (rate/retention, AvE/AvT, segmentation) using BDX and internal data. Act as a strategic partner to Program Underwriting, CFO, and DDS, turning analytics into clear recommendations and supporting new program...

The Graphic Design Specialist is an integral part of the Emergent Holdings communications team and will manage projects from ideation and design to production with adherence to the Emergent Holdings brand standards and the ability to drive a consistent visual identity. Based in the Detroit or Grand Rapids areas, this person will lead design projects for the division, including brand development, corporate identity, corporate presentations, infographics, print and digital advertising, website design, and trade show graphics – all aligned to support strategic, measurable goals. Working knowledge of SharePoint sites, websites, HTML and WordPress required. The Graphic Design Specialist must have strong multimedia design skills, be highly motivated, organized and detail-oriented with the ability to perform multiple tasks simultaneously and adapt to changing priorities. This person must also be able to collaborate and thrive in a small team, work under tight timelines with changing...

Position Title Director Employee Relations (Banking & Financial Services ER) Location Hicksville, NY 11801 Job Summary The Director - Employee Relations leads Flagstar’s Employee Relations function and serves as a trusted advisor to Human Resources, Legal, Risk partners and the enterprise on complex workplace matters. This role is responsible for establishing and executing the Bank’s employee relations strategy, ensuring consistent application of policies and practices, mitigating employment-related risk, and fostering a fair, respectful, and compliant workplace culture. The Director leads a team of Employee Relations professionals and provides expert guidance on investigations, performance management, workplace conduct, conflict resolution, accommodations, policy interpretation, and other employee relations matters. This role balances risk management with practical business solutions while supporting the Bank’s culture and strategic objectives; monitoring the effect...

Description Summary:  The Institutional Supervisory Administration Manager, Institutional Asset Management & Trust is responsible for managing the administration, compliance, and risk aspects of the Institutional Asset Management & Trust practice as well as complex client support activities for institutional clients, including those in unique industries and those with specialized administration. This position is responsible for day-to-day administration, operational and risk management activities, in terms of the establishment, documentation, and maintenance, and best practices in servicing client relationships. The position manages a team of Service Specialists and/or Account Administrators, including supervising operational workflow and monitoring work completion, providing regular guidance, coaching, and training, and ensuring adherence to policies and procedures. The position will report to the...

Description Summary Huntington Bank is seeking a Technical Recovery Senior Consultant to join our Enterprise Resilience team. The Senior Consultant assists in developing, implementing, and maintaining strategies and standards, processes, and procedures for ensuring integrity and availability of Huntington’s data, systems, technologies, and critical business functions. The incumbent participates in risk management analysis and assists with the creation of business continuity and disaster recovery plans. Works with business representatives, service owners, and IT teams to develop and execute testing processes to validate recovery plans and the overall resilience capabilities of the organizations. Manages a repository of business continuity, disaster recovery, and resilience material including plans and documentation that will be accessible in the event of service interruption or disaster. Duties and...