30 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 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 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...

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...

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 The candidate selected for this position as Protective Security Operations Center (PSOC) Director will lead and manage the daily operations of our centralized security command  center . This role provides strategic oversight and operational control for the PSOC and Alternate PSOC (APSOC) teams, ensuring effective...

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. This is a remote position. 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...

The Hospital Bill Audit Manager is responsible for planning, leading, and coordinating multiple teams of nurse auditors and associated billing staff in a fast paced, productivity-based environment. This role oversees auditors performing varying types of medical bill audits including, but not limited to, medical record audits, hospice, implant, and outpatient or ancillary facility claims. This team also performs onsite and remote hospital bill audits. Must be willing to travel for onsite facility audits and other meetings as needed.   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 results Assist the Hospital Bill Supervisor in the training, professional development, and retention for the nurse auditors Ensure accuracy of audits through acquired knowledge of client policies, provider contract information, and other...

The Recovery Supervisor is responsible for analysis and monitoring of claims audit data across multiple platforms. 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 claims processing. 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: Manage team performance by setting and communicating standards and deadlines, measuring results, and providing feedback. Maintain positive morale by leading the team through example and accountability with a focus on helping each member achieve their best performance...

Operations Data Associate About Us: HUB International is a global insurance and employee benefits broker offering a broad range of risk management, life and health, investment, and wealth management solutions. Our Retirement & Private Wealth division serves clients across the full wealth spectrum, with assets managed across multiple registered investment advisors. About HUB Retirement & Private Wealth (RPW): We operate at the intersection of financial advisory and technology — and we take both seriously. Our platform team is responsible for the data integrity, operational infrastructure, and technology governance that make client-facing work possible. We hold ourselves to a high standard on that, and we want teammates who do the same. We are the perfect fit if you: Enjoy team collaboration and thrive in a culture that recognizes success Want to learn, grow, and take on increasing responsibility Have an entrepreneurial spirit and are energized by...

- The Senior Support Analyst role combines both analytical and technical skills.   This role is responsible for ensuring the successful ingestion and validation of Bordereau data files from insurance agencies. This role plays a critical part in verifying data layout and schema compliance, analyzing data quality, building and managing data pipelines & data flows to ingest data and designing insightful experience reporting using Power BI. The analyst serves as a key liaison between internal teams and external partners to ensure data integrity and reporting excellence. Key Accountabilities/Deliverables: Engage with insurance agencies to review and validate Bordereau file layouts for ingestion readiness. Confirm data schemas align with internal ingestion requirements and standards. Analyze and validate data fields for completeness, accuracy, and consistency. Build and maintain data pipelines and dataflows within Microsoft Fabric (e.g., Dataflows Gen2, Pipelines)....

Job Title: Payroll Specialist Compensation: $25-$30 per hour plus 6% discretionary bonus Location: Hybrid in Austin, TX (Hybrid) Department: Operations Job Type: Full-Time Working Hours: 8:00am-5:00pm CST (Monday-Friday) About Us: HUB is a global insurance and employee benefits broker, providing a broad array of property, casualty, risk management, life and health, employee benefits, investment and wealth management products and services. About HUB Retirement & Private Wealth (RPW):  We lead our communities with integrity, driven to make things better, both now and in the future. We serve, inspire, and thrive while maintaining an entrepreneurial spirit. We innovate, collaborate, and achieve success together, focused on the tomorrows for all. Job Purpose: We are looking for a meticulous and communicative Payroll Processing Specialist to join our team in Austin, TX. In this hybrid role, you will work three days per week from our Austin office...

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 will be hybrid out of our Dallas, TX or Overland Park, KS office. 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 Utilization Review activities...

Primary Details Time Type: Full time Worker Type: Employee At QBE, we are always looking to connect with top talent – for current vacancies as well as for future opportunities. It is our aim to continuously build a strong candidate pipeline across all our businesses and key locations in North America. After submitting your interest to this specific hiring profile, our Recruitment Team will review your credentials and areas of expertise. Should there be a current or prospective opportunity that is commensurate with your career experience, we will contact you for an exploratory discussion. We appreciate your consideration of QBE as an employer of choice. The Opportunity This role will deliver prompt and accurate claims service to policyholders and agents for both multi-peril crop insurance (MPCI) and crop hail claims by completing field inspections, communicating with involved parties, performing investigations, determining appropriate adjustments and...

About HUB: HUB International is a global insurance broker providing a broad array of property, casualty, risk management, life and health, employee benefits, investment and wealth management products and services. HUB has more than 650 offices across the United States, Canada and Puerto Rico with more than 21,000 employees. Our regional offices throughout North America are dedicated to helping individuals and businesses evaluate and manage their risks and insurance needs.  We are a company dedicated to superior customer service with employees committed to adding value to every client activity. Job Summary: The Account Manager plays 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 small business commercial lines insurance clients. As the key liaison, you will build and maintain strong, positive relationships with both our...