28 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. This is a remote position. ESSENTIAL FUNCTIONS & RESPONSIBILITIES: The Clinical Auditor will review medical records to determine accuracy of billing through...

CERIS is seeking a DRG Coder/Clinical Auditor. The Diagnostic Related Groups (DRG) Clinical Auditor will be responsible for performing DRG validation (clinical/coding) reviews of medical records and/or other documentation to determine correct DRG/coding and clinically supported as defined by review methodologies specific to the type of review. This involves completing medical records review, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination. Experience using ICD-10-CM & PCS coding guidelines, the ability to understand modern pharmacology, disease management and clinical intervention procedures.  The ideal DRG Clinical Auditor candidate will have strong oral and written communication skills, clinical knowledge of disease process, and knowledge of medical necessity rules. This is a remote position. ESSENTIAL FUNCTIONS & RESPONSIBILITIES: The Clinical Auditor will review medical records to...

The Diagnostic Related Groups (DRG) Clinical Auditor will be responsible for performing DRG validation (clinical/coding) reviews of medical records and/or other documentation to determine correct DRG/coding and clinically supported as defined by review methodologies specific to the type of review. This involves completing medical records review, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination. Experience using ICD-10-CM & PCS coding guidelines, the ability to understand modern pharmacology, disease management and clinical intervention procedures.  The ideal DRG Clinical Auditor candidate will have strong oral and written communication skills, clinical knowledge of disease process, and knowledge of medical necessity rules. This is a remote position.   ESSENTIAL FUNCTIONS & RESPONSIBILITIES: The Clinical Auditor will review medical records to determine accuracy of billing through...

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 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...

Why GM Financial?   GM Financial is the wholly owned captive finance subsidiary of General Motors and is headquartered in Fort Worth, U.S. We are a global provider of auto finance solutions, with operations in North America, South America, and the Asia Pacific region. Through our long-standing relationships with auto dealers, we offer attractive retail financing and lease programs to meet the needs of each customer. We also offer commercial lending products to dealers to help them finance and grow their businesses.   At GM Financial, our team members define and shape our culture — an environment that welcomes new ideas, fosters integrity, and creates a sense of community and belonging. Here we do more than work — we thrive.   Our Purpose:  We pioneer the innovations that move and connect people to what matters   This position will be posted until filled. The Accountant II prepares journal entries, difficult and involved reconciliations, researches and resolves...

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. The Opportunity USAA’s Compensation Principal serves as a highly visible, strategic business partner and recognized subject matter expert, driving significant impact across the Association. This role leads the design, development, and administration of sophisticated compensation programs, providing expert consultation, in-depth analysis, and strategic advice to HR Business Partners, business leaders, and HR centers of excellence. The Compensation Principal proactively identifies and analyzes market trends, ensures regulatory...

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...

The Payment Integrity Supervisor is responsible for the daily activities of payment integrity team related to quality assurance and provider appeals. The Supervisor manages and prioritizes staff daily work assignments necessary to ensure the timely and accurate processing of internal and external requests, interdepartmental quality audits and appeals. Additionally, the supervisor works to reduce response timeframes and mitigate future inquiries or escalations by being proactive, taking ownership of challenges, and formulating solutions to improve overall department activities while maintaining a focus on improving how we deliver service to our customers.  This is a remote position. ESSENTIAL FUNCTIONS AND RESPONSIBILITIES: Supervises all daily activities of payment integrity team related to quality assurance and provider appeals Ability to assist team with problem-solving, payer policy and clinical questions regarding audits performed by CERIS Ability to...

Role Details Job Title: Senior Manager, Investment Accounting Location: Houston, TX (Hybrid 4:1) Reports To: VP, Corporate Controller Employment Type: Full time About Us Help us insure it. Tokio Marine HCC is a leading global specialty insurance group, backed by the strength and stability of the Tokio Marine Group. With more than 50 years of sustained growth and profitability, and offices across the United States, the United Kingdom, Europe, and other international locations, we offer more than 100 classes of specialty insurance—covering everything from the crops that feed us and the concerts that entertain us to rescuing travelers abroad. Guided by our Mind Over Risk philosophy, we empower clients to pursue opportunities with confidence while fostering a culture rooted in innovation, collaboration, and trust. Always Advancing, we embrace an entrepreneurial spirit; as Experts in Tomorrow, we anticipate what’s next; and by Reaching Out, we build genuine connections...

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 PRIMARY PURPOSE : Provides disability case management and routine claim determinations based on medical documentation and the applicable disability plan interpretation including determining benefits due and making timely payments/approvals and adjustments, medically managing disability claims; coordinates investigative efforts, thoroughly reviewing contested claims, negotiates return to work with or without job accommodations, and evaluates and...

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 Qualified candidates must live near one of Centers of Excellence in the following locations to work a hybrid schedule - Irving, TX : 2201 W. Royal Lane Suite 125 Irving, TX 75063 West Hills, CA : 8521 Fallbrook Ave West Hills, CA 91304 PRIMARY PURPOSE : Provides disability case management and routine claim determinations based on medical documentation and the applicable disability plan interpretation including...

The Diagnostic Related Groups (DRG) Clinical Supervisor is responsible for performing DRG validation (clinical/coding) 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 review forms, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination. This is a remote position. ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Supervises all daily activities of the DRG Clinical Auditors Demonstrated knowledge of, ICD-10-CM and PCS codes, and DRG coding, understanding of payer rules and regulations, including Medicare and Medicaid with the ability to work independently with minimal supervision and demonstrate initiative Completes DRG audits as needed Responsible for the overall integrity of the quality of diagnosis and...

Why GMF Technology?   Innovation isn’t just a talking point at GM Financial, it’s how we operate. From generative AI and cloud-native technologies to peer-led learning and hackathons, our tech teams are building real solutions that make a difference. We’re committed to AI-powered transformation, using advanced machine learning and automation to help us reimagine customer interactions and modernize operations, positioning GM Financial as a leader in digital innovation within a dynamic industry.   Join us and discover a workplace where your ideas matter, your development is prioritized, and you can truly make a global impact. Please note, this role is hybrid at our AOC 1 office in Arlington, TX (2 days onsite, 3 days remote) About this role The Global Infrastructure Data Transmission Administrator III will assist as a high-level subject matter expert in the day-to-day tasks critical to the team's success. This individual will focus on the support and implementation of...

 Why GMF Technology? Innovation isn’t just a talking point at GM Financial, it’s how we operate. From generative AI and cloud-native technologies to peer-led learning and hackathons, our tech teams are building real solutions that make a difference. We’re committed to AI-powered transformation, using advanced machine learning and automation to help us reimagine customer interactions and modernize operations, positioning GM Financial as a leader in digital innovation within a dynamic industry.   Join us and discover a workplace where your ideas matter, your development is prioritized, and you can truly make a global impact.   Please note: this is a hybrid position requiring 2 days onsite in Arlington, TX. About this role The Software Engineering Manager is accountable for the delivery and ongoing support of Commercial Lending technology solutions within a highly regulated banking environment. This role ensures that all engineering activities adhere to established...

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....

UFG is looking for an Underwriting Associate to join our Southwest Region.  In this role you will assist with underwriting insurance risks in accordance with the business plan and delegated authority to meet business objectives, ensuring compliance with internal and external regulations and guidelines. This role is responsible for providing technical underwriting and administrative support to the underwriting staff to ensure timely and streamlined processes to best serve agents and insureds. This role works to gather information, prepare file documentation, collaborate with internal partners, and assist underwriters with agent interactions. Responsibilities: Analyze underwriting information to triage, prepare and respond to quotes, renewals and policy endorsements or inquiries as granted within assigned underwriting authority. Apply underwriting guidelines as published and ensure compliance with all company filings, rules, and regulations. Underwrite and process all...

Who Are We? Taking care of our customers, our communities and each other. That’s the Travelers Promise. By honoring this commitment, we have maintained our reputation as one of the best property casualty insurers in the industry for over 170 years. Join us to discover a culture that is rooted in innovation and thrives on collaboration. Imagine loving what you do and where you do it. Job Category Underwriting Compensation Overview The annual base salary range provided for this position is a nationwide market range and represents a broad range of salaries for this role across the country. The actual salary for this position will be determined by a number of factors, including the scope, complexity and location of the role; the skills, education, training, credentials and experience of the candidate; and other conditions of employment. As part of our comprehensive compensation and benefits program,...

Our Account Managers play a critical role in ensuring clients receive the support they need to effectively manage their insurance policies. In this position, you are responsible for servicing and retaining commercial lines insurance clients. As the key liaison, you will build and maintain strong, positive relationships with both our valued clients and insurance carrier partners. Responsibilities include managing a book of commercial lines accounts, marketing to carriers, preparing quotes and proposals, responding promptly to policy inquiries via email and phone, maintaining renewal controls for expirations and binders, reviewing policies, endorsements, and audits for accuracy, and keeping accurate, organized account files. In this role, you will: Maintain a book of commercial accounts Coordinate the processing of all commercial lines new and renewal business Work with producers to maintain synergy with HUB International corporate goals, our carrier requirements, and...

Why GMF Technology?   Innovation isn’t just a talking point at GM Financial, it’s how we operate. From generative AI and cloud-native technologies to peer-led learning and hackathons, our tech teams are building real solutions that make a difference. We’re committed to AI-powered transformation, using advanced machine learning and automation to help us reimagine customer interactions and modernize operations, positioning GM Financial as a leader in digital innovation within a dynamic industry.   Join us and discover a workplace where your ideas matter, your development is prioritized, and you can truly make a global impact. Flexible hybrid work environment (onsite 2 days a week/3 days remote) at our Arlington (AOC1), TX office. About this role:   The Global Workload Automation Delivery Engineer II will support the optimization of workload automation tools used by GMF IT.  The position will develop and implement processes in the workload software, attend project...