33 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...

The position is described below. If you want to apply, click the Apply button at the top or bottom of this page. You'll be required to create an account or sign in to an existing one. If you have a disability and need assistance with the application, you can request a reasonable accommodation. Send an email to Accessibility (accommodation requests only; other inquiries won't receive a response). Regular or Temporary: Regular Language Fluency:  English (Required) Work Shift: 1st Shift (United States of America) Please review the following job description: This role is a Product Owner in the Scaled Agile Framework who partners with product managers to balance business, technology and design priorities to deliver brand-defining product and service experiences. The position requires the ability to understand strategic impacts but concentrates on the day-to-day details in order to ensure tactical execution. The Product Owner is responsible for executing...

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:       Irving, TX : 2201 W. Royal Lane Suite 125 Irving, TX 75063   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...

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 Fraud Model Management Lead will be a senior team member, working with other staff and their Director to implement first-line model management activities on a portfolio of fraud and financial crimes models, while closely partnering with Bank Financial Crimes leadership, Enterprise Model Risk Management (MRM), Legal,...

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 is accountable for stabilizing and leading a critical pillar, with a strong focus on team alignment, operational performance, and enterprise impact. The leader will build strong relationships, assess current operations and transformation priorities, and establish a clear path forward for structure and performance....

About HUB: HUB International is a top 5 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 19,000 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. This position is in our downtown San Antonio office and offers a hybrid schedule (3 days office; 2 days remote) after an initial onboarding period. Summary: The Personal Lines Account Manager is responsible for managing the entire account-service process, marketing clients to various carriers, responding to client inquiries regarding coverage and eligibility, ensuring the...

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. This position will be posted until filled.  About the role: The Global Workload Automation Delivery Engineer III, under the general direction of the Global Workload Automation Manager, will assist in the day-to-day tasks critical to the WLA team's success.  This individual will become familiar with all compliance, regulatory and security requirements,...

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 As a member of the Argo Security Engineering & Architecture   Team   you will   be responsible for   staying up to date with recent cybersecurity threats and technologies.  This is an entry-level position focusing on protecting Argo’s information systems and networks.  This role involves monitoring security systems,   identifying   vulnerabilities and exposures, and implementing scalable corrective measures to enhance protection.     A successful person in this role will have strong   organizational   skills including the ability to manage time across several areas of focus, the ability to communicate...

The position is described below. If you want to apply, click the Apply button at the top or bottom of this page. You'll be required to create an account or sign in to an existing one. If you have a disability and need assistance with the application, you can request a reasonable accommodation. Send an email to Accessibility (accommodation requests only; other inquiries won't receive a response). Regular or Temporary: Regular Language Fluency:  English (Required) Work Shift: 1st Shift (United States of America) Please review the following job description: This role is a Product Owner in the Scaled Agile Framework who partners with product managers to balance business, technology and design priorities to deliver brand-defining product and service experiences. The position requires the ability to understand strategic impacts but concentrates on the day-to-day details in order to ensure tactical execution. The Product Owner is responsible for executing...

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...

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 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 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...

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...

Company Details     Berkley Oil & Gas, a W. R. Berkley Company, is an innovative market leader dedicated to providing unique products and services tailored to the needs of businesses operating in the energy industry. We have a deep understanding of our clients’ operations and the exposures they face, and we make it a priority to stay well informed of the changing dynamics in the industry. With well over 250 years of combined energy experience, our objective is to provide total account solutions to our customers. This includes specialized coverages, risk services that complement existing safety practices, and claims management that reflects our in-depth knowledge of hazards and losses normal to this industry.     Company URL: https://berkleyoil-gas.com/   The company is an equal opportunity employer. Responsibilities The Chief Underwriting Officer is responsible for providing strategic direction and...

Come join one of America’s fastest-growing insurance companies. Since 1848, National Life Group has aimed to keep our promises, providing families with stability in good times and in bad. Throughout that history, we have provided peace of mind to those families as they plan their futures. Our mission extends beyond the insurance and annuities policies that we offer. We strive to make the world a better place through our grants from our charitable foundation, paid volunteer time for our employees, environmentally sustainable and healthy workplaces, and events that promote the work of nonprofits in our own backyard. We foster a collaborative environment with opportunities for growth and encourage our associates to live our values: Do good. Be good. Make good. Please note that we do not offer visa sponsorship for this position. Role Summary This leadership position will play a critical role in the Customer and Agent Experience within our New Business area of...