28 clinical review auditor jobs found in Fort Worth, TX

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...

The PPI Coordinator plays a key role in supporting the Policy and Payment Integrity teams by managing workflow, ensuring timely assignment of appeals, and maintaining accurate tracking systems. This position required strong organizational skills, attention to detail, and the ability to manage multiple priorities in a fast-paced environment. This is a remote position. Essential Functions & Responsibilities: Manage and monitor general PPI department mailboxes to ensure timely review and routing of incoming correspondence Assign appeals to appropriate team embers based on established workflows and production needs Maintain and update appeal trackers to ensure accurate and current data is available for reporting and performance monitoring Track the status of assign appeals to support timely completion and compliance with internal expectations and external deadlines Identify workflow delays or discrepancies in tracking systems and escalate to leadership as...

Why Regulatory Compliance Examination Manager at GM Financial?  The Regulatory Compliance Examination Manager role offers a unique opportunity to make a meaningful, enterprise wide impact. As the leader overseeing federal and state examination activities, this position plays a central role in shaping how the organization demonstrates compliance and manages regulatory risk. The work is highly visible and influential, involving regular collaboration with senior executives, Legal, Internal Audit, Analytics, and business partners across the enterprise. You will guide the full exam lifecycle, strengthen controls, and drive impactful process and system enhancements. This is an ideal role for a leader who wants to shape compliance strategy, enhance organizational readiness, and play a critical part in advancing the company’s regulatory posture. At GM Financial, our team members define and shape our culture — an environment that welcomes innovative ideas, fosters integrity, and creates...

The Hospital Bill Audit Nurse conducts hospital bill charge audits by reviewing medical records to verify that services were provided and charges are appropriate based on medical documentation and industry guidelines. The types of audits performed could include, but are not limited to inpatient, outpatient, NICU, and hospice. Charge audits identify overcharges, undercharges, and unbundled items per payor contract and industry standards. This role is responsible for independent scheduling requiring flexibility and travel to provider location.    This is a remote position with travel required. ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Acknowledge assigned work, maintain timely communication with Audit Coordinator, schedule and complete audits in an efficient and timely manner Travel onsite as needed to perform audits Review medical records to verify services were provided and charges are accurate – identify overcharges/undercharges, unbundled items, errors,...

The Payment Integrity Analyst is responsible for accurately reviewing pre and post pay claim audits based on client, policy, industry standards and/or CMS guidelines. This is a remote position. ESSENTIAL FUNCTIONS AND 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.  Ability to use clinical judgement and analytical skills to appropriately review documentation submitted for claim audits. Utilize 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, All Company Meetings, Education Opportunities, Trainings, and...

The IT Compliance Analyst supports the organization’s compliance and risk management programs by coordinating assessments, audits, and certifications across frameworks such as HITRUST, SOC, HIPAA, and NIST. This role helps maintain a strong IT compliance posture by managing evidence, monitoring control performance, maintaining documentation, and partnering closely with IT, Security, Privacy, Legal and external auditors. The Analyst also contributes to continuous improvement efforts, compliance automation initiatives, and reporting that supports leadership visibility and informed decision-making.   Key Responsibilities Assessment & Audit Support Coordinate internal and external compliance assessments, audits and certifications. Prepare, organize, and manage evidence to meet control and audit requirements. Track remediation activities and ensure timely closure of identified gaps. Maintain audit-ready documentation and support readiness reviews. Additional...

The Policy and Payment Integrity Manager oversees the PPI team and assists with implementation of policies to perform reviews conducted by CERIS, including but not limited to itemized bill review, professional review, hospital outpatient and DRG validation. This role manages   members of the PPI team, developing team strengths and improving weaknesses, identifying team goals, and evaluating team progress. The Policy and Payment Integrity Manager provides trend analysis of internal auditing of claims for accuracy related to pre- and post-payment claims, targeted claims, high dollar claims, and any other claim or record that requires quality review. The role assists with development of internal quality assurance measures based on client policy and industry guidelines. The manager also aids in researching and implementing best practices related to (CMS) payment policies, healthcare policies, client, state, and/or policy initiatives. This is a remote role.   ESSENTIAL...

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...

Why GM Financial 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. About this role: The IT Compliance Analyst II, will participate in and lead IT compliance initiatives for GM Financial.  As the direct interface between audit groups and the Information Technology Department, the IT Compliance Analyst is responsible for providing guidance to management on critical aspects of external and internal audit...

Amerisure creates exceptional value for its partners, policyholders, and employees. As a property and casualty insurance company, Amerisure’s promise to our partner agencies and policyholders begins with a comprehensive line of insurance products designed to protect businesses, as well as the health and safety of every employee. With an A.M. Best “A” (Excellent) rating, Amerisure serves mid-sized commercial enterprises focused in construction, manufacturing and healthcare. Ranked as one of the top 100 Property & Casualty companies in the United States, we proudly manage nearly $1 Billion of Direct Written Premium and maintain $1.21 billion in surplus. Amerisure is currently recruiting for a Senior Auto/GL Claims Quality Consultant that can do a hybrid approach in one of our offices. This role will focus on our auditing for our auto and general liability side of the house.  The ideal candidate will also possess the following skill set.  Summary Statement...

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 Disability Representative Our teams thrive together! We collaborate in person and embrace a flexible hybrid work style. To join us, you’ll need to live near our dynamic Center of Excellence📍 Irving, TX. 2201 W. Royal Lane Suite 125 Irving, Tx 75063 ✨ What we offer: A stable, consistent work environment —both in-office and virtual A comprehensive training program to help you support employees and customers from some of the...

Company Details     At Berkley Entertainment, we have over 25 years of underwriting risks in Entertainment & Sports.  Our one focus is entertainment insurance. We bring our decades of entertainment experience together to go beyond the basics, providing crafted coverage solutions to protect our clients.   Our team’s industry experience and collaborative approach leads to great client solutions — and this is by design. We are here to assist with customizing products and services that are tailored to respond to each client’s unique exposures.   The Company is an equal employment opportunity employer. Responsibilities As a Premium Auditor, you’ll play a critical role in ensuring accurate premium calculations and compliance across multiple regions. You’ll review and evaluate financial records to verify classification and exposure reporting and collaborate with internal teams to deliver precise audit results. You’ll...

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...

Overview AmTrust Financial Services, a fast-growing commercial insurance company, has a need for a Clinical Pharmacist. This role is out of one of our office locations in the United States on a hybrid schedule.   PRIMARY PURPOSE:  The Clinical Review Pharmacist has the responsibility of reviewing the medical necessity, appropriateness, and quality in the appropriate setting for workers’ compensation injured employee as it pertains to their medications. Additionally, they will work with Amtrust adjusters and nurses to take proper interventions in the care of the injured employee. This position primarily requires timely reviews of pharmacy prior authorizations to determine appropriateness and medical necessity of treatment. This position assesses the medical appropriateness of proposed medications for our injured employees and partners with the AmTrust claims team to expedite medically necessary treatment. Responsibilities...

With a company culture rooted in collaboration, expertise and innovation, we aim to promote progress and inspire our clients, employees, investors and communities to achieve their greatest potential. Our work is the catalyst that helps others achieve their goals. In short, We Enable Possibility℠. Position Summary: The Assistant Vice President within Arch Construction Specialty Products is responsible for the day-to-day technical underwriting and account management of construction professional liability (PL) and contractor’s pollution (CPL) book of business.  Responsibilities and Accountabilities: 1. Technical Underwriting Solicits and reviews new and renewal account information required to evaluate a risk. Identifies all potential exposures and hazards in relation to coverage requested and individual risk characteristics. Engage other internal resources as necessary Underwrites prices and prepares proposals based on objective and subject risk...

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...