32 clinical review auditor jobs found

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...

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...

Overview The Clinical Product Manager (CPM) shapes and optimizes ancillary healthcare services in workers’ compensation, overseeing processes and vendors managing: DME, PT/OT, diagnostics/imaging, transportation/translation, home health, IME/peer review and other supporting vendors related to managed care medical spend. This cross-functional role blends strategy, clinical insight, and operational execution to improve outcomes, reduce costs, and enhance experiences for injured workers, adjusters, and clinical teams. Collaboration with vendors, stakeholders, and leadership is essential to drive measurable improvements and ensure program integrity.   Amtrust is looking for a critical thinker who can bring structure and innovation to our workers’ compensation managed care programs. In this role, you will own vendor performance and process management in a broad variety of areas — making sure the right partners are in place, performance stays strong, and programs...

 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....

Company Details 2025 Business Insurance Best Places to Work winner , Berkley Southwest offers commercial property and casualty products and services through independent agents in Arizona, Arkansas, New Mexico, Oklahoma, and Texas. We maintain a strong local presence in each of our markets, keeping underwriting and support close to the customer.   Now more than ever, financial strength is critical to a successful, long term insurance relationship. Berkley Southwest is a member company of W. R. Berkley Corporation , a Fortune 500 company, whose insurance company subsidiaries are rated A+ (Superior) by A.M. Best.   This position will be based in either our Irving, Texas or San Antonio, Texas offices where we offer a hybrid work schedule with 4 days in the office; and 1 day remote where it makes sense to do so.   The company is an equal opportunity employer.   #LI-hybrid, #LI-LD1   Responsibilities As...

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...

Company Details     2025 Business Insurance Best Places to Work winner, Berkley Southwest  offers commercial property and casualty products and services through independent agents in Arizona, Arkansas, New Mexico, Oklahoma and Texas. We maintain a strong local presence in each of our markets, keeping underwriting and support close to the customer.    Now more than ever, financial strength is critical to a successful, long term insurance relationship. Berkley Southwest is a member company of W. R. Berkley Corporation , a Fortune 500 company, whose insurance company subsidiaries are rated A+ (Superior) by A.M. Best.  #LI-LD1 #LI-HYBRID   This position will be based in our Irving, TX office.   We offer a hybrid work schedule with 4 days in the office; and 1 day remote where it makes sense to do so.    The company is an equal opportunity employer.   Responsibilities As a Manager, Underwriting ,...

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 As an Audit Lead, you'll support audit engagements of varying complexity, often participating in cross-functional, risk-based assurance and advisory projects, contributing to the quality of audit work. A key aspect of this role involves testing models and model-related tools as part of audit engagements. You will support Auditor-In-Charge (AIC) responsibilities and maintain knowledge of financial services regulations, effectively responding to and interacting with regulators. This role provides support 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 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 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...

Starr Insurance Companies is a leading insurance and investment organization, providing commercial property and casualty insurance, including travel and accident coverage, to almost every imaginable business and industry in virtually every part of the world. Cornelius Vander Starr established his first insurance company in Shanghai, China in 1919. Today, we are one of the world’s fastest growing insurance organizations, capable of writing in 128 countries on 6 continents. Position Overview We are looking for an Account Service Director for the Energy & Environmental Team to handle Energy Accounts over $500,000 in total premium and manage the Account Service Managers in Energy and Environmental Profit Centers.  The Account Service Director is the single point of contact for all clients and brokers for any service-related matters.  The Account Service Director will conduct kick-off calls, claim reviews, account management and stewardship meetings.  They will proactively...

Job Description: Avant Specialty Benefits is seeking a detail‑oriented, service‑driven Centralized Leave Management Coordinator to support one of our dedicated clients in navigating the complexities of employee leave. This role is ideal for someone who thrives on providing exceptional support, ensuring regulatory compliance, and enhancing the employee experience during critical life events. In this role, you will guide employees, HR partners, and internal stakeholders through leave of absence processes, deadlines, and documentation requirements. Drawing upon your knowledge of FMLA, ADA, and state-specific leave laws, you will help ensure employees receive the accommodations and support they need—promoting accessibility, inclusion, and compliance every step of the way. What You’ll Do Coordinate FMLA and disability programs in accordance with Federal and State laws as well as company procedures. Serve as the primary point of contact for FMLA questions and eligibility...

Who We Are.   At We Insure Group, we are passionate, driven, and purposeful in our mission to personalize protection at the right value. We believe in delivering tailored insurance solutions that meet each client’s unique needs, ensuring they feel confident and supported in every decision.     As both a franchise platform and direct insurance provider, We Insure empowers like-minded entrepreneurs with the opportunity to own and operate successful agencies. With over 200 locations across 35 states, we support our agency owners, customers, and carrier partners by enabling faster service, greater efficiency, better choices, and improved results.     What sets us apart? We’re data-driven for better value and people led for better service. Our purpose is rooted in clarity, guidance, and long-term trust helping individuals and business owners make informed choices about their insurance coverage. We're building something meaningful and looking for...