320 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...

Company Shared Services Argo and Farm Family are specialty property and casualty insurance brands whose underwriting companies are wholly-owned subsidaries of Clearbrook Holdings Inc. Argo and Farm Family partner with agents and brokers to provide insurance solutions that enable businesses to manage risks with confidence. Job Description RESPONSIBILITIES: Only Considering local candidates at this time Must be a US Citizen or Green Card holder. No other visa status will be considered. Serve as the first point of contact for end users by providing technical support via live chat, self-service portal, and phone Diagnose, troubleshoot, and resolve hardware, software, and application-related incidents and service requests Document, categorize, prioritize, and manage incidents and requests accurately within the ticketing system Use published Knowledge Base (KB) articles to ensure consistent, compliant, and efficient issue resolution Ask targeted...

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 Sr. Medicare Associate PRIMARY PURPOSE To gather documentation required to complete Medicare Compliance referrals in a timely manner; to upload referrals to Medicare Compliance System (MCS); to review the pay histories and medical records for adequacy; and to resolve technically difficult record files. ESSENTIAL RESPONSIBLITIES MAY INCLUDE Reviews JURIS pay ledger as a guide to locate medical records needed for MCS assignment; analyzes additional...

Senior Director, Premium Payables, Accounting & Finance Operations About Acrisure A global fintech leader, Acrisure empowers millions of ambitious businesses and individuals with the right solutions to grow boldly forward. Bringing cutting-edge technology and top-tier human support together, we connect clients with customized solutions across a range of insurance, reinsurance, payroll, benefits, cybersecurity, mortgage services – and more.  In the last twelve years, Acrisure has grown in revenue from $38 million to almost $5 billion and employs over 19,000 colleagues in more than 20 countries. Acrisure was built on entrepreneurial spirit. Prioritizing leadership, accountability, and collaboration, we equip our teams to work at the highest levels possible. Job Summary: Acrisure is seeking a Senior Director to lead the Premium Payables function to join our growing team in Grand Rapids, MI.  This position will report to the Vice President, Accounting &...

This is your opportunity to join AXIS Capital – a trusted global provider of specialty lines insurance and reinsurance.  We stand apart for our outstanding client service, intelligent risk taking and superior risk adjusted returns for our shareholders. We also proudly maintain an entrepreneurial, disciplined and ethical corporate culture.  As a member of AXIS, you join a team that is among the best in the industry. At AXIS, we believe that we are only as strong as our people. We strive to create an inclusive and welcoming culture where employees of all backgrounds and from all walks of life feel comfortable and empowered to be themselves. This means that we bring our whole selves to work.  All qualified applicants will receive consideration for employment without regard to race, color, religion or creed, sex, pregnancy, sexual orientation, gender identity or expression, national origin or ancestry, citizenship, physical or mental disability, age, marital status, civil...

This role is a highly managerial position focused on leading the Help Desk, overseeing day to day operations, and ensuring that all support activities are executed with consistency, quality, and accountability. The position requires a confident leader who can manage people, processes, and performance at a high standard.   Minimum Qulifications: Minimum of five years of hands-on help desk support experience. Minimum of three years of experience in a managerial role overseeing Help Desk or IT operations, with five years preferred. ServiceNow ITSM and ServiceNow platform experience preferred. Experience working within ITIL frameworks and applying IT service management best practices in a Help Desk or IT operations environment.   Primary Job Functions: Leadership and Operational Oversight Provides full management and oversight of daily ticket volume, including prioritization, assignment, distribution of work, and overall workflow coordination. Serves...

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 hybrid out of Irvine, CA, Scottsdale, AZ or Salt Lake City, UT.  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...

Overview AmTrust Financial Services, a fast-growing commercial insurance company, has an opportunity for a Manager, RN Branch Manager of Telephonic Case Management for Workers Compensation where your clinical talent and leadership abilities contribute to our competitive edge.    PRIMARY PURPOSE: The RN Branch Manager for telephonic case management services will oversee operations as well as a team of experienced worker’s compensation nurse case managers. The ideal candidate will have a minimum of three (3) or more years’ experience overseeing a nursing claims management program as well as in-depth understanding of worker’s compensation injury claims and utilization management review programs. The Manager will lead the nurse case management team to strategize with claim professionals in management of medical and disability exposure, delivering quality telephonic case management to proactively drive best in class outcomes including appropriate medical...

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...

This is an opportunity to join Ascot Group – one of the world’s preeminent specialty risk underwriting organizations. Designed as a modern-era company operating through an ecosystem of interconnected global operating platforms, the employees of Ascot are bound by a common mission and purpose: One Ascot.  Ascot’s greatest strength is a talented team of professionals who flourish in a collaborative, inclusive, and entrepreneurial culture, steeped in underwriting excellence, integrity, and a passion to find a better way, The Ascot Way. The Ascot Way guides people and strategic direction.  Underwriting platforms collaborate to find creative ways to deploy capital in a true cross-product and cross-platform approach. These platforms work as one through a unique Fusion Model: Client-Centric, Risk-Centric, Technology-Centric. Built to be resilient, Ascot maximizes client financial security while delivering bespoke products and world class service — both pre- and post-claim. Ascot...

Company Shared Services Argo and Farm Family are specialty property and casualty insurance brands whose underwriting companies are wholly-owned subsidaries of Clearbrook Holdings Inc. Argo and Farm Family partner with agents and brokers to provide insurance solutions that enable businesses to manage risks with confidence. Job Description The IT Service Desk Supervisor is responsible for the overall operational health, performance, and maturity of the Service Desk function. This role provides direct people leadership, oversees 24x7 support operations (including overnight coverage), serves as an escalation point for complex and critical incidents, and drives continuous improvement initiatives such as shift‑left adoption, knowledge maturity, and access management process adherence. The Supervisor ensures consistent service delivery aligned to SLA, ITIL, security, and audit requirements, while fostering a high‑performing, customer‑focused support team. KEY...

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 Sr   Our teams connect! We collaborate onsite and have a hybrid work arrangement. All candidates must live near one of our centers of excellence: Southfield, MI : 300 Galleria Officentre Southfield MI 48034 PRIMARY PURPOSE : Provides disability case management and complex claim determinations based on medical documentation and the applicable disability plan interpretation including determining benefits due and making timely...

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 Risk Analyst PRIMARY PURPOSE :  Gathers, analyzes, and presents information on various risk management initiatives; manages certificate of insurance requests, security arrangements and inquiries for international travel, and maintains vital risk management information.  ESSENTIAL FUNCTIONS and RESPONSIBILITIES Manages all certificate of insurance requests including handling non-standard broker and carrier requests, ensuring new certificates are correct 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 Claims Team Lead Assistant - Workers Compensation | Roseville, CA Are you looking for an opportunity to join a global industry leader where you can bring your big ideas to help solve problems for some of the world’s best brands?   Apply your knowledge and experience to adjudicate complex customer claims in the context of an energetic culture.  Deliver innovative customer-facing solutions to clients who represent virtually every industry and comprise...

At OneAmerica Financial, our purpose is to create more certainty for our customers that leads to better moments, every day. Our commitment is to advance stability and growth in every solution and relationship.  We deliver financial strength that builds for generations, and we are always aspiring, looking ahead, and collaborating to achieve more, together.  Come be a part of this journey with us as we champion lives! Job Summary: The Senior Underwriting Consultant for Supplemental Health insurance plays a critical role within our Group Employee Benefits Underwriting Dept. to Underwrite for and assist with the launch of new Supplemental Health Product offerings to help OneAmerica meet sales and profitability targets. Core Focus: Support the launch of our new Supplemental Health Products including Accident, Critical Illness, and Hospital Indemnity.  Act as the subject matter expert (SME) for Supplemental Health products including creating and delivering training for...

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...