Claim auditor work from home jobs

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Louisiana, Iowa, and Idaho with planned expansion into other states in 2024. For more information, visit AmHealthPlans.com. If you would like to be part of a collaborative, supportive and caring team, we look forward to receiving your application! Benefits and Perks include: * Affordable Medical/Dental/Vision insurance options * Generous paid time-off program and paid holidays for full time staff * TeleMedicine 24/7/365 access to doctors * Optional short- and long-term disability plans * Employee Assistance Plan (EAP) * 401K retirement accounts * Employee Referral Bonus Program ESSENTIAL JOB DUTIES: To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation. * Conduct pre-pay and post-pay audits to ensure accurate claims payments and denials * Ensure regulatory compliance and overall quality and efficiency by utilizing strong working knowledge of claims processing standards * Work closely with delegated claim processor to ensure errors are reviewed and corrected prior to final payment * Work assigned claim projects to completion * Provide a high level of customer service to internal and external customers; achieve quality and productivity goals * Escalate appropriate claims/audit issues to management as required; follow departmental/organizational policies and procedures * Maintain production and quality standards as established by management * Participate in and support ad-hoc audits as needed * Other duties as assigned JOB REQUIREMENTS: * Proficient in processing/auditing claims for Medicare and Medicaid plans * Strong knowledge of CMS requirements regarding claims processing, especially regarding skilled nursing facilities and other complex claim processing rules and regulations * Current experience with both Institutional and Professional claim payments * Knowledge of automated claims processing systems * Hybrid role that may require 2-3 days per week onsite at the Franklin, TN office. REQUIRED QUALIFICATIONS: * Experience: * Two (2) years' experience with complex claims processing and/or auditing experience in the health insurance industry or medical health care delivery system * Two (2) years' experience in managed healthcare environment related to claims processing/audit * Two (2) years' experience with standard coding and reference materials used in a claim setting, such as CPT4, ICD10 and HCPCS * Two (2) years' experience with CMS requirements regarding claims processing; especially Skilled Nursing Facility and other complex claim processing rules and regulations * Two (2) years' experience processing/auditing claims for Medicare and Medicaid plans * License/Certification(s): * Coding certification preferred EQUAL OPPORTUNITY EMPLOYER Our Organization does not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. The Organization will also make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made. This employer participates in E-Verify.

We are a hybrid, remote-office company dedicated to growing our talent anywhere! We have onsite locations in: Sioux Falls, SD, Scottsdale, AZ, Louisville, KY, Troy, MI, Franklin, TN, Easton, PA. At Pathward, we take tremendous pride in our purpose to create financial inclusion for all™. We are a financial empowerment company that works with innovators to increase financial availability, choice, and opportunity for all. We strive to remove barriers that traditional institutions put in the way of financial access, and promote economic mobility by providing responsible, secure, high quality financial products. We are a team of problem solvers and innovators who celebrate our differences and know that our unique perspectives make us stronger and well-positioned for success. We celebrate, and embrace, our team members through our *HUMBLE*HUNGRY*SMART approach, and we believe that we are strongest when we embrace the voices of our employees, customers, partners, and the communities we serve. About the Role: Independently plans and executes complex, risk‑based audits with a primary focus on BSA/AML, sanctions (OFAC), and Partner Solutions (embedded finance/“BaaS”). The role applies deep financial‑crimes and partner‑oversight expertise to assess governance, risk management, and control effectiveness across Pathward's products, services, and third‑party ecosystems. Leveraging sound judgment, data‑driven analysis, and plain‑language storytelling, this position develops actionable insights, influences senior stakeholders, and drives continuous improvement, while adhering to the IIA Standards and Pathward's Internal Audit methodology, and expectations from regulatory bodies such as the OCC and FinCEN. While the core emphasis is on financial‑crimes and partner‑banking risks, this position will also lead audits in adjacent domains (e.g., operations, payments and money movement, consumer compliance) as business needs dictate. The ideal candidate thrives in ambiguity, navigates complex business models and technology stacks, and communicates with clarity and empathy to build trust and deliver high‑quality outcomes. Experience engaging with regulatory bodies is highly valued. What You Will Do: Plan and lead end‑to‑end, risk‑based audits (planning, fieldwork, reporting, and follow‑up). Set clear objectives/scope/criteria; identify key risks and controls; tailor procedures to business model and risk profile; deliver on time with high quality. Evaluate BSA/AML program pillars, governance and oversight, risk assessments, internal controls, policies and standards, training, and monitoring/quality assurance. Test financial‑crimes processes: CIP/KYC/CDD/EDD, customer risk rating, watchlist screening, transaction monitoring, investigations, SAR/CTR obligations, model validation and coverage, and recordkeeping across platforms and partners. Assess sanctions (OFAC) compliance: governance, interdiction, alert handling, escalation, and intersections across payments and money‑movement rails. Audit Partner Solutions (BaaS) and related third-party oversight including BSA/AML and OFAC compliance across the partner lifecycle: due diligence, onboarding, ongoing monitoring, change management, issue management, and termination. Review BSA/AML and OFAC third-party risk classification, oversight practices, and compliance reporting for sufficiency, accuracy, and decision usefulness. Use data analytics, where possible, to profile population risk, select samples, and detect anomalies across screening, monitoring, disputes, and partner portfolios. Evaluate enterprise interdependencies affecting BSA/AML and OFAC by testing data from source to report, testing ownership and SLAs at handoffs, and identifying gaps so processes are reliable, well‑controlled, and decision‑useful. Assess rules/models/scenarios and data pipelines: change control, documentation, performance monitoring/back‑testing, and data lineage/integrity supporting BSA/AML and OFAC. Produce clear, evidence‑based findings with root‑cause analysis, business impact, and prioritized action plans; challenge management responses and validate remediation (including regulatory items) for sustained effectiveness. Engage stakeholders constructively (business leaders, Compliance, Risk, Technology); present concise, executive‑ready narratives/visuals; escalate emerging risks promptly and tailor messaging to audiences (working groups, executives, committees). Lead non‑financial‑crimes audits as needed (e.g., payments and money movement (ACH/wires/RTP)), consumer compliance, third‑party risk management, and model risk-applying the same risk‑based methodology and clear, audience-tailored reporting. Coordinate co‑sourced providers, ensuring adherence to methodology, templates, workpaper quality, and delivery timelines. Support annual risk assessment and audit planning with insights on regulatory themes, partner risks, product/technology changes, and data/controls maturity. Exemplify ethics and judgment: integrity, objectivity, confidentiality, and sound judgment under uncertainty/complexity. Demonstrate strong interpersonal effectiveness: active listening, constructive feedback, patience and perseverance, collaborative relationships, compassion and respect, customer focus, and disciplined planning to achieve audit goals. Stay abreast of emerging issues involving internal audit, changes to federal and state banking laws, and evolving laws and regulations that could impact the organization, particularly with BSA/AML and sanctions, BaaS, third party risk, prepaid products and/or deposit products, consumer payment applications/wallets, and/or digital or electronic payments processing/processors. Assist in the development of less-experienced staff through the review of audit work papers and timely feedback. Other duties as assigned. What You Will Need: Bachelor's degree in a relevant field (e.g., Accounting, Finance, Business, or related displace), or equivalent education and work Professional certifications such as: CAMS, CFE, CIA, CRMA, and/or CPA preferred. Additional credentials in BSA/AML, or sanctions compliance are a plus. 5+ years of relevant experience in internal audit, compliance, or risk within financial services. Demonstrated strength in BSA/AML, sanctions, and partner/third‑party oversight. Ability to pivot and lead audits in adjacent domains. Proficiency with data‑centric testing and visualization techniques; strong written and verbal communication. The responsibilities listed above are not all inclusive and may be changed at any time. Salary range: $72,000 - $120,000 The salary range reflects the minimum and maximum target for a new hire in this role. Individual pay within the range will be determined by multiple factors which can include but are not limited to a candidate's experience, qualifications, skills, and location. Your recruiter can share more about the specific salary for your location during the hiring process. Ranges may be modified in the future. This role is also eligible for an annual performance-based incentive opportunity. Pathward offers a comprehensive benefits package for eligible employees, including health insurance, 401(k) retirement benefits, life insurance, disability benefits, paid time off, and more. #LI-Remote Don't have everything listed under qualifications? If you're excited about this role but your experiences don't match exactly to everything in the posting, we encourage you to apply anyway. You may be just the right candidate for this or other Pathward roles. Pathward is an equal employment opportunity employer and considers candidates for roles without regard to their race, sex, national origin, ethnicity, age, disability or any other category protected by law. Who we are: Our commitment to inclusion is woven into our DNA. We believe that we are strongest when we embrace the voices of our employees, customers, partners, and the communities we serve. We provide equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, ethnicity, religion, sex, sexual orientation, gender identity, transgender status, pregnancy, national origin, age (age 40 and over), disability, genetic information, marital status, hair texture or hairstyle, ancestry, service in the uniformed services, protected veteran status, status as a victim of domestic violence or any other class protected by federal, state and local laws. Please click here to learn more about our benefits and review information about our Privacy Policy, Affirmative Action Plan and other notices. Applicants with disabilities may be entitled to reasonable accommodation under the terms of the Americans with Disabilities Act and certain state or local laws. For assistance completing an application, please contact a Pathward People & Culture Representative by emailing - ******************** Please click here to view Pathward's Applicant Privacy Notice. Applications will be accepted for a minimum of 3 days after posting, and there is no predetermined date by which applications should be submitted. Knowingly submitting false information will result in disqualification for consideration of future positions, termination of employment and forfeiture of other rights. Candidate Scam Warning We encourage you to be cautious of hiring scams that impersonate Pathward. Copy and paste the following URL into your browser to learn more: *********************************************************

At Equitable, our power is in our people. We're individuals from different cultures and backgrounds. Those differences make us stronger as a team and a force for good in our communities. Here, you'll work with dynamic individuals, build your skills, and unleash new ways of working and thinking. Are you ready to join an organization that will help unlock your potential? Equitable is seeking an influential and dynamic Claims Examiner to join our Group Life Claims organization. Claims Examiner is responsible for providing excellent customer service. You will be expected to utilize judgment and assess risk as you work with various business partners to render claim decisions. Key Job Responsibilities Claims Management: Responsible for active case management of Life claims. Ensures claims are processed accurately within regulatory and company guidelines. Deliver an exceptional customer experience and ensure that customer commitments and deliverables are achieved. Review and interpret medical records, utilizing resources as appropriate. Complete financial calculations specific to claims when applicable. Gain an understanding and working knowledge of the Equitable claim and other applicable systems, policies, procedures, and contracts as well as regulatory and statutory requirements for claim adjudication. Apply contract/policy provisions to ensure accurate eligibility and liability decisions. Demonstrate and apply analytical and critical thinking skills. Client and Customer Relationships: Foster strong relationships with customers to understand their needs and ensure high levels of satisfaction. Addresses and resolves any customer challenges or concerns promptly. Communication via telephone, email, and text with employees, employers, attorneys, and others. Provide timely and exceptional customer experience by paying appropriate claims accurately and timely, responding to all inquiries and maintaining expected service and quality standards. Work within a fast-paced environment, with tight deadlines, and demonstrate the ability to balance multiple priorities. Work independently as well as within a team structure. The base salary range for this position is $53,000 - $62,000. Actual base salaries vary based on skills, experience, and geographical location. In addition to base pay, Equitable provides compensation to reward performance with base salary increases, spot bonuses, and short-term incentive compensation opportunities. Eligibility for these programs depends on level and functional area of responsibility. For eligible employees, Equitable provides a full range of benefits. This includes medical, dental, vision, a 401(k) plan, and paid time off. For detailed descriptions of these benefits, please reference the link below. Equitable Pay and Benefits: Equitable Total Rewards Program Required Qualifications · 2+ years prior experience managing Life claim products. · Excellent client relationship management skills. · Strong verbal, written communication, and presentation skills. · Comfortable dealing with complexity and ambiguity and able to explore multiple solutions. Preferred Qualifications · Previous experience with FINEOS Claims software platform highly desired. · Exceptional customer service skills; Proven skills in positive and effective interaction with challenging customers. · Strong knowledge of regulatory requirements for Life claims. · Ability to handle sensitive information with confidentiality and professionalism. · Strong written and oral communication skills demonstrated in previous work experience. · Excellent organizational and time management skills with ability to multitask and prioritize deadlines. · Ability to manage multiple and changing priorities. · Detail oriented; able to analyze and research contract information. · Demonstrated ability to operate with a sense of urgency. · Experience in effectively meeting/exceeding individual professional expectations and team goals. · Demonstrated analytical and math skills. · Ability to exercise critical thinking skills, risk management skills and sound judgment. · Ability to adapt, problem solve quickly and communicate effective solutions. · High level of flexibility to adapt to the changing needs of the organization. · Self-motivated, independent with proven ability to work effectively on a team and work with others in a highly collaborative team environment. · Continuous improvement mindset · A commitment to support a work environment that fosters diversity and inclusion. · Strong computer literacy and skills with the ability to work within multiple systems; proficiency with PC based programs such as Excel and Word. · Reliability and dependability throughout our extensive training program is crucial. Skills Analytical Thinking\: Knowledge of techniques and tools that promote effective analysis; ability to determine the root cause of organizational problems and create alternative solutions that resolve these problems. Customer Support Operations\: Knowledge of customer support techniques, tools, technologies, and best practices; ability to utilize all aspects of customer support operations to manage a call center. Customer Support Systems\: Knowledge of principles and techniques used in customer support and ability to use applications, hardware, software, networking, and the applications environment used for customer support. Managing Multiple Priorities\: Knowledge of effective self-management practices; ability to manage multiple concurrent objectives, projects, groups, or activities, making effective judgments as to prioritizing and time allocation. Problem Solving\: Knowledge of approaches, tools, techniques for recognizing, anticipating, and resolving organizational, operational or process problems; ability to apply knowledge of problem solving appropriately to diverse situations. #LI-Remote ABOUT EQUITABLE At Equitable, we're a team committed to helping our clients secure their financial well-being so that they can pursue long and fulfilling lives. We turn challenges into opportunities by thinking, working, and leading differently - where everyone is a leader. We encourage every employee to leverage their unique talents to become a force for good at Equitable and in their local communities. We are continuously investing in our people by offering growth, internal mobility, comprehensive compensation and benefits to support overall well-being, flexibility, and a culture of collaboration and teamwork. We are looking for talented, dedicated, purposeful people who want to make an impact. Join Equitable and pursue a career with purpose. ********** Equitable is committed to providing equal employment opportunities to our employees, applicants and candidates based on individual qualifications, without regard to race, color, religion, gender, gender identity and expression, age, national origin, mental or physical disabilities, sexual orientation, veteran status, genetic information or any other class protected by federal, state and local laws. NOTE\: Equitable participates in the E-Verify program. If reasonable accommodation is needed to participate in the job application or interview process or to perform the essential job functions of this position, please contact Human Resources at ************** or email us at *******************************.

A Career at HARMAN As a technology leader that is rapidly on the move, HARMAN is filled with people who are focused on making life better. Innovation, inclusivity and teamwork are a part of our DNA. When you add that to the challenges we take on and solve together, you'll discover that at HARMAN you can grow, make a difference and be proud of the work you do every day. Introduction: A Career at HARMAN Corporate We're a global, multi-disciplinary team that's putting the innovative power of technology to work and transforming tomorrow. At HARMAN Corporate, you are integral to our company's award-winning success. Enrich your managerial and organizational talents - from finance, quality, and supply chain to human resources, IT, sales, and strategy Augment your comprehensive skillset with expert training across decision-making, change management, leadership, and business development Obtain 360-degree support throughout your career life cycle, from early-stage to seasoned leader About the Role The Trade Compliance Auditor is responsible for auditing customs-related import and export compliance within the United States, Canada and EMEA regions. This role serves to audit all compliance-related functions in the regions. This role reports to the Audit Manager, Trade Compliance. You will create and maintain trade compliance procedures and requirements to support the growth from an audit perspective. What You Will Do Responsible for executing against the auditing standards and performance criteria, managing audits. Complete an initial risk assessment of the regional trade compliance operation. Create both a line level audit review and more strategic “deep dive” audit plan. Create a comprehensive audit plan that feeds into the Global Trade Compliance audit strategy. Create regional KPIs based on audit results. Work closely with the Trade Compliance Operations team to communicate findings and follow through until sufficient risk is mitigated. Present regional audit results. Audit to ensure proper customs valuation, classification, country of origin. Planning, scheduling, coordinating, reviewing and reporting on compliance metrics within the trade compliance value chain. Ensure that local risk management frameworks and processes are aligned with global ones and address risks. Work closely within the audit team to ensure cohesiveness across all audit regions. Monitor and audit of regional import and export processes and documentation to ensure compliance with trade laws. Test processes for adherence to Harman's Trade Compliance Policy, manuals and internal procedures. Prepare audit reports & gap analysis, proposed remediation measures and targeted training to foster continuous improvement across the trade compliance value chain. Monitor to ensure Trade Compliance recordkeeping requirements are followed, including adherence to Standard Operating Procedures (SOP's). Identify and integrate ‘best practices' standards for the organization based on global cooperation. Build partnerships with third-party customs brokerage firms and trade compliance service providers. What You Need to Be Successful Bachelor's degree in Trade Compliance or related field. Experience in auditing trade-related functions preferred. 7+ years of experience in Trade Compliance operations. Global/multinational mindset and awareness. Areas of Expertise: Customs compliance; export/import activities; documentation; HTS classification. Experience with US, CA, and EMEA compliance operation Bonus Points if You Have Customs Broker License (LCB) or Certified Customs Specialist (CCS) credentials Experience with Thomson Reuters OneSource or similar global trade management (GTM) software Expertise with automotive parts and consumer electronics commodities is a plus Multi-cultural awareness and ability to adjust communication accordingly. What Makes You Eligible Be willing to travel up to 10% domestic and international travel. Be willing to work in an hybrid office environment and/or fully remote, with occasional trips into the office required. What We Offer Flexible work environment, allowing for full-time remote work globally for positions that can be performed outside a HARMAN or customer location Access to employee discounts on world-class Harman and Samsung products (JBL, HARMAN Kardon, AKG, etc.) Extensive training opportunities through our own HARMAN University Competitive wellness benefits Tuition reimbursement “Be Brilliant” employee recognition and rewards program An inclusive and diverse work environment that fosters and encourages professional and personal development #LI-JS247 #LI-Remote Salary Ranges: $ 76,500 - $ 112,200 HARMAN is proud to be an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.

About Us Health Admins is a leading third-party administrator in the healthcare space. Our Vision is to radically improve the way individuals interact with the healthcare system. We are committed to providing innovative and efficient health care solutions to our clients, ensuring they receive the best possible care and service. Our team is currently seeking a highly skilled and experienced Claims Processor to join our dynamic team. What We Are Looking For Our ideal candidate will play a crucial role in managing our Medical Claims environment, optimizing its performance, and driving continuous improvements to support our business goals and enhance our service delivery. Every Team Member is Driven by a Commitment to Live out These Values: Be Authentic: Be true and honest Be Helpful: Pitch in and help Be Innovative: Seek & embrace innovation Be Accountable: Do what you say you are going to Employees are expected to embrace our core values by being “A Hero in Action.” These values lay the foundation for the way we engage with each other and with our clients. They form the guardrails for our decision making and approach to problem solving. Summary/Objective: We seek a meticulous and customer-focused individual to join our team as a Claims Processor. This role requires a combination of research acumen, attention to detail, and exceptional customer service skills. As a key member of our organization, you will be responsible for processing medical claims accurately, conducting thorough audits to ensure compliance with regulations and policies, and providing excellent service to our clients and healthcare providers. Key Responsibilities: Review and process medical claims submitted by members or providers promptly and accurately. Verify the accuracy and completeness of claim information, including patient demographics, diagnoses, procedures, and billing codes when available. Ensure compliance with insurance policies and industry standards. Investigate and resolve any discrepancies or issues related to claim submissions. Conduct comprehensive medical claims audits to identify errors, discrepancies, or fraudulent activities. Analyze claim documentation, including medical records and billing statements, to ensure adherence to coding guidelines and reimbursement policies. Research complex medical billing and coding issues to support claims processing and audit activities. Interpret coding guidelines, reimbursement policies, and legal requirements to determine appropriate claim adjudication. Provide recommendations for improving claims submission procedures and enhancing reimbursement accuracy. Serve as members' primary point of contact regarding claims inquiries and resolution. Respond promptly to customer inquiries and concerns with professionalism and empathy. Collaborate with cross-functional teams to address customer issues and ensure timely resolution. Skills Required: Strong knowledge of medical terminology, medical coding, and insurance billing practices. Excellent analytical skills with the ability to interpret complex healthcare regulations and guidelines. Exceptional attention to detail and accuracy in data entry and documentation. Effective verbal and written communication skills with a customer-centric approach. Ability to work independently and collaboratively in a fast-paced, deadline-driven environment. Excellent verbal, written and interpersonal communication skills; Must be a self-motivator and self-starter; Exceptional listening and analytical skills; Solid time management skills; Ability to multitask and successfully operate in a fast paced, team environment; Must adapt well to change and successfully set and adjust priorities as needed; Education/Experience: High School Diploma or equivalent Proven experience in medical claims processing and healthcare reimbursement Technical Knowledge: SalesForce Experience Google Suite Experience Claims Management Software experience What We Offer Competitive salary and benefits package Dynamic and innovative work environment Opportunities for professional growth and development Remote work flexibility Equal Opportunity Statement We are deeply committed to building a workplace and global community where inclusion is not only valued but prioritized. We are proud to be an equal opportunity employer, seeking to create a welcoming and diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, family status, marital status, sexual orientation, national origin, genetics, neuro diversity, disability, age or veteran status, or any other non-merit based or legally protected grounds. We are committed to providing reasonable accommodation to qualified individuals with disabilities in the employment application process.

Why MSI? We thrive on solving challenges. As a leading MGA, MSI combines deep underwriting expertise with insurer and reinsurer risk capacity to create specialized insurance solutions that empower distribution partners to meet customers' unique needs. We have a passion for crafting solutions for the important risks facing individuals and businesses. We offer an expanding suite of products - from fully-digital embedded renters coverage to high-value homeowners insurance to sophisticated commercial coverages, such as cyber liability and habitational property - delivered through agents, brokers, wholesalers and other brand partners. Our partners and customers count on us to deliver exceptional service through a dedicated team that makes rapid resolutions a priority. We simplify the insurance experience through our advanced technology platform that supports every phase of the policy lifecycle. Bring on your challenges and let us show you how we build insurance better. The Claims Examiner is considered an expert in managing insurance claims for our policyholders. The Claims Examiner must have technical knowledge in insurance claims handling and the skills needed to provide superior service for our customers. The ability to develop relationships and effectively communicate with a diverse range of clients, carriers and colleagues is a key success factor in this role. Strategic vision coupled with tactical execution to achieve results in accordance with goals and objectives is also critical to the overall success of this position. PRIMARY RESPONSIBILITIES: • Investigates and analyzes claim information to determine extent of liability. • Handles claims 1st Party Property Claims. • Assist in suits, mediations and arbitrations. Works with Counsel in the defense of litigation. • Sets timely, adequate reserves in compliance with the company's reserving philosophy. • Engages experts to assist in the evaluation of the claim. • Monitors vendor performance and controls expense costs. • Evaluates, negotiates and determines settlement values. • Communicates with all interested parties throughout the life of the claim. Proactively discusses coverage decisions, the need for additional information, and settlement amounts with interested parties. • Handles all claims in accordance with Best Practices. • Responsible for monitoring and completing assigned claims inventory. • Acquire and maintain a state adjuster's license and meet state continuing education requirements. • Provides Best-In-Class customer service for insureds and agents. • Updates and maintains the claim file. • Identifies opportunities for subrogation and ensures recovery interests are protected. • Identifies fraud indicators and refers files to SIU for further investigation. • Participates in claims audits, internal and external. • Provides oversight of TPAs KNOWLEDGE, SKILLS & ABILITIES: EDUCATION & EXPERIENCE: High School/GED 2-3 years' experience in claims Must have Property & Casualty Insurance License #LI-BM1 #LI-REMOTE Click here for some insight into our culture! The Baldwin Group will not accept unsolicited resumes from any source other than directly from a candidate who applies on our career site. Any unsolicited resumes sent to The Baldwin Group, including unsolicited resumes sent via any source from an Agency, will not be considered and are not subject to any fees for any placement resulting from the receipt of an unsolicited resume.

SUMMARY DESCRIPTION: The Residential Claims Examiner is responsible for approving and settling residential property claims from the field where an estimate of damage has been prepared, or for preparing and settling estimates, or documenting claims decisions and settling those claims with the policyholder and claimants. The role's primary duties include phone scoping, reviewing coverage, determining settlement amounts, communicating with the policyholder or their representative, and documenting the claim file as outlined by the client or RENFROE. They are also responsible for documenting all activity, submitting required claims documentation, issuing settlement payments, settling and closing the claim using fair claims settlement practices, and ensuring compliance with legal and contractual obligations. REPORTS TO: Assigned RENFROE Manager ESSENTIAL JOB FUNCTIONS: · Follows RENFROE and clients' policies and procedures to handle all assigned property claims · Works with the RENFROE Manager and other adjusters to share knowledge and experience and to gain new skills · Assigns task work for property inspections and interacts with field adjusters and estimators to determine the scope of loss · Oversees claims files for assigned claims and updates claims as new information becomes available using the client's proprietary software · Manages the progression of claims/tasks and claim inventories assigned to them · Contacts and interacts with the policyholder or their representative to obtain documents such as purchase receipts, bills, photographs, or other documents to establish the existence, ownership, and value of the items claimed damaged · Determines coverage and amounts for additional living expenses such as rental housing, travel, meals, etc. · Sets claim reserves following the client's guidelines · Calculates settlement amounts and, within their settlement authority or after receiving requested authority from the client's designee, issues settlement checks with supporting claim documentation · Writes closing reports, including recommendations for the pursuit of subrogation or the disposal of salvage · Reviews the claim file to support and draft coverage decision letters · Maintains required jurisdictional adjusting licenses as required by the client and/or RENFROE · Does not handle claims for which they do not have client authorization or for which they are not licensed · Participates and communicates in client team meetings to discuss claim handling trends, team production, and any claim handling concerns or changes · Makes suggestions on ways to improve process efficiency · Participates in special projects and completes other duties as assigned Non-Authorized Activities: Claims Examiners should not: · Communicate training requirements to client staff adjusters and non-affiliated firms · Communicate training requirements to any claim handler who is not deployed with RENFROE · Discuss Human Resource issues with any client staff adjusters in any segment or any claim handler that is not deployed with RENFROE · Discuss any of the following topics with a client staff adjuster or any claim handler that is not deployed with RENFROE: job openings, termination, prior work history, attendance, absence requests, daily work schedule, claim volume or workload, meal and rest break schedule, promotions, development, compensation, or mentoring of any kind EXPERIENCE/QUALIFICATIONS: · Minimum of 1 year of property claims experience is preferred · Participation in technical insurance coursework is preferred, such as CPCU · Experience using various claims processing systems is preferred · Appropriate licenses, depending on state requirements, and successful completion of required/applicable claims certification training classes · Effective problem resolution and decision-making skills to include analyzing insurance policies and information, demonstrating sound judgment, and utilizing one's own experience and the experience of others · Strong analytical skills and consistent attention to detail · Knowledge of ISO forms, and client policy coverage, procedures, and systems · Communicates clearly and effectively, both verbally and in writing · Strong customer service orientation and good rapport with the insured · Well-organized and hard-working, with the ability to thrive in a fast-paced work environment · Strong interpersonal skills and proven ability to establish good relationships with clients, RENFROE management, employees, and others with whom they interact · Computer skills, including but not limited to practical knowledge of Word and Excel PHYSICAL DEMANDS: · Sitting in a chair for extended periods of time · Ability to operate a telephone, computer, mouse, keyboard, and other similar equipment for extended periods of time · Extended and varying work schedules, which may include work from home or work from a centralized office · Regular attendance required, working up to 12 hours a day, 7 days a week, for extended periods of time, including weekends and holidays · Ability to work in a fast-paced, changing, and multi-tasking environment

This position is responsible for the oversight of complex and large exposure losses and will report to the National Casualty Claims Manager. The Casualty Claims Examiner will work alongside claims management, providing direction and oversight ensuring that compliance with best practices and state/local guidelines is achieved. In addition, this position will report findings and make recommendations on current practices including the claim department's performance on meeting regulatory standards. Job Responsibilities · Review home office casualty files, provide direction as required to ensure that handling is within best practice guidelines and local jurisdiction regulations. · Responsible for providing guidance and direction to claims staff in order to ensure proper handling and risk mitigation. · Provide authority and guidance on all bodily injury claims regarding coverage, liability and damages, as required. · Provide feedback to leadership and adjusting staff as required for continually improved file handling. · Responsible for collaboration with claims staff, front line claims management, senior claims management and legal counsel. · Available to answer questions and participate in roundtable discussions with claims staff and management to provide feedback and guidance on claim handling procedures. · Complete research pertaining to complex coverage issues, industry trends, and related topics. · May assist with targeted audits of a particular process or function (e.g. total loss handling, BI evaluations, cycle times, regulatory reviews, customer service skills, etc.) and/or management re-audits to verify calibration and accuracy of the first level reviews completed. · Assist in designing and delivering casualty training as needed to ensure compliance and proper claim handling Job Qualifications Formal Education & Certification Bachelor's degree or equivalent work experience Knowledge & Experience · A minimum of five years of adjusting claims. At least two years adjusting/overseeing casualty claims with high complexity. · Prior claims management experience and/or auditing preferred. Skills & Competencies · Communication and analytical ability at a level to interact with associates, managers, agents and vendors. · Demonstrated team building and coordination skills. · Must possess strong interpersonal skills and the ability to present critical information to Senior Management. · Ability to manage multiple priorities and work independently. · Leadership abilities are necessary, with the ability to make autonomous decisions based on multiple facts. · Must be able to work in a fast-paced automated production environment and possess solid planning and organizational skills including time management, prioritization, and attention to detail. · Must meet company guidelines for attendance and punctuality and professional appearance/decorum. This indicates the essential responsibilities of the job. The duties described are not to be interpreted as being all-inclusive to any specific associate. Management reserves the right to add to, modify, or change the work assignments of the position as business needs dictate. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job. This job description does not represent a contract of employment. Employment with AssuranceAmerica is at-will. The at-will relationship can be terminated at any time, with or without reason or notice by either the employer or the associate. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

At DUAL North America, our core values dictate how we live and work. We are a group with independence and people at its heart and we are a home for talent with a unique culture: the biggest small company in the world. The focus on being a People First business has always been at the very heart of the Group; Our vision was to create an independent business with a unique culture and one that would survive and thrive as a business controlled by the people working for it. And finding the most talented and entrepreneurial people to join the Group has been and will continue to be key. DUAL North America, Inc. is seeking a Claims Examiner - Construction Defect Classification: Exempt/Full-time • Reports to: Claims Manager • Travel: 0-10% • Salary/hourly: $100,000.00-$120,000.00 Role overview DUAL North America is seeking a Casualty Examiner for the Construction Defect Claims team. At DUAL, Casualty Examiners play a critical role in managing and resolving insurance claims with accuracy and efficiency, while complying with state regulatory requirements. In this role, you will investigate claims, analyze policy coverages, and collaborate with internal and external stakeholders to ensure claim resolution. Supporting the Construction Defect Claims team, you will independently manage low to moderate exposure claims involving alleged defects in residential and commercial construction. Role responsibilities • Initiate timely contact with all relevant parties upon claim assignment • Handle low to moderate exposure construction defect claims involving residential and commercial projects. • Analyze insurance policies to determine applicable coverage • Draft and issues coverage position letters • Negotiate settlements • Ensure all claim activities comply with DOI regulations and internal policies • Retain and coordinate with defense counsel and experts while managing litigation plans and budgets to ensure effective case resolution • Maintain timely, accurate, and complete documentation of all claim activities and decisions • Collaborate with underwriting, and internal teams to share insights and coordinate claim strategies • Provide feedback to business partners to support continuous improvement in claims handling Key requirements • Bachelor's degree preferred • Professional designations (CPCU, SCLA, AIC, JD) are a plus • 2-7 years of construction defect claims experience is preferred with consistent high level of performance and achievement • Must be licensed or have the ability to become licensed in all required states • Proficiency in Microsoft Office Suite (Word, Excel, Outlook, PowerPoint) • Knowledge of industry trends and legal developments affecting claims handling • Ability to manage multiple claims and competing priorities • Ability to adapt to evolving regulatory and legal environments • Complete assigned tasks correctly, on time and able to learn quickly • Self-motivated and demonstrating attention to detail • Be able to work independently for extended periods • Excellent written and verbal communication skills as well as general business understanding • Must be able to remain in a stationary position 50% of the time, with occasional movement in the office to access cabinets and equipment • If you do not meet all the qualifications for this role, we still encourage you to apply, as we are always looking for diverse talent to join our growing team. What we offer: A career that you define. Yes, we offer all the usual rewards and benefits - including medical, dental, vision, a wide variety of wellbeing offers, competitive salary, unlimited PTO, 401k with company match, paid volunteer days and more. We provide an environment where new ideas are encouraged and celebrated, where people who want to have a real hand in our success thrive. We want people who want to make a difference - not just in the workplace, but in the industry and in the wider community. EEO Statement: We consider our people our chief competitive advantage and as such we treat colleagues, candidates, clients, and business partners with equality, fairness, and respect. DUAL North America provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. DUAL will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.

Reserv is an insurtech creating and incubating cutting-edge AI and automation technology to bring efficiency and simplicity to claims. Founded by insurtech veterans with deep experience in SaaS and digital claims, Reserv is venture-backed by Bain Capital and Altai Ventures and began operations in May 2022. We are focused on automating highly manual tasks to tackle long-standing problems in claims and set a new standard for TPAs, insurance technology providers, and adjusters alike. We have ambitious (but attainable!) goals and need adjusters who can work in an evolving environment. If building a leading TPA and the prospect of tackling the long-standing challenges of the claims role sounds exciting, we can't wait to meet you. About the role We are seeking a skilled BI-LIT Claims Examiner to manage litigated files and attend trials, conferences, mediations, and arbitrations. The successful candidate will: Investigate and gather all necessary information and documentation related to claims Evaluate liability and damages Negotiate and settle claims Manage litigation cases related to auto claims disputes The BI-LIT Claims Examiner will also be responsible for maintaining electronic files, analyzing defense counsel's performance, and regularly reporting to the Claims Manager. In addition, you will collaborate closely with our product and engineering teams to give feedback and identify technology and process improvements. Who you are Highly motivated and growth-oriented. You're excited by the prospect of building a tech-driven claims org. Passionate adjuster who cares about the customer and their experience. Empathetic. You exercise empathy and patience towards everyone you interact with. Sense of urgency - at all times. That does not mean working at all hours. Creative. You can find the right exit ramp (pun intended) for the resolution of the claim that is in the insured's best interest. Conflict-enjoyer. Conflict does not have to be adversarial, but it HAS to be conversational. Curious. You have to want to know the whole story so you can make the right decisions early and action them to a prompt resolution. Anti-status quo. You don't just wish things were done differently, you action on it. Communicative. (we'd love to know what this means to you) And did we mention, a sense of humor. Claims are hard enough as it is. What we need We need you to do all the things typical to the role: Managing legal aspects of litigated cases, including evaluation of legal process and expenses Analyzing and reviewing auto insurance claims to identify areas of dispute, investigating and gathering all necessary information and documentation related to the claim, evaluating liability and damages related to the claim, and negotiating and settling claims with opposing parties or their insurance providers Managing litigation cases related to auto claims disputes, attending mediations, arbitrations, and court hearings as necessary, and communicating regularly with clients, claims adjusters, attorneys, and other stakeholders Collaborating with defense counsel, claims counsel, and litigation claims management for strategic planning, including developing and maintaining positive working relationships with approved defense firms and other vendors in the industry Reviewing legal documents and ensuring compliance with initial suit-handling plan of action Serving as corporate representative for discovery review and depositions, and appearing as Corporate Representative at depositions and trials when needed Analyzing policy language and reaching appropriate coverage decisions, drafting frequent and complex coverage correspondence, and proactively managing primarily litigated claim files from inception to closure Directing and controlling the activities and costs of numerous outside vendors including defense counsel and coverage counsel, experts and independent adjusters Maintaining adjuster licenses and continuing education requirements Requirements Bachelor's degree (lack of one should not stop you from applying if you possess all the other qualifications) 10+ years of claim handling experience, with 5+ of those years handling a pending of >60% in litigation Transportation litigation (rideshare, auto, trucking, etc) is preferred but those with personal lines experience should still apply if they meet all other requirements. You are not intimidated by an attorney, even if you are not one! You are the driver of the litigation strategy for any particular claim. You manage the discovery in the order and timing of events and hold attorney accountable Understand transportation coverages. Understand contractual risk transfer and additional insured forms You have strong medical knowledge You have a sense of urgency and understanding of how to manage time-sensitive demands Ability and willingness to communicate both on the phone and in written form in a prompt, courteous, and professional manner Strong analytical and negotiation skills. You will conduct your own negotiations directly with opposing counsel Knowledge of multiple state statutes, including good faith claim handling practices, regulations, and guidelines Ability to professionally collaborate with all stakeholders in a claim Have active adjuster license(s) and be willing to obtain all licenses within 45 days, including completing state required testing Attention to detail, time management, and the ability to work independently in a fast-paced, remote environment Curious and motivated by problem solving and questioning the status quo Desire to engage in learning opportunities and continuous professional development Willingness to travel for client and claims needs Benefits Generous health-insurance package with nationwide coverage, vision, & dental 401(k) retirement plan with employer matching Competitive PTO policy - we want our employees fresh, healthy, happy, and energized! Generous family leave policy Work from anywhere to facilitate your work life balance Apple laptop, large second monitor, and other quality-of-life equipment you may want. Technology is something that should make your life easier, not harder! Additionally, we will Provide a manageable pending for you to deliver the service in a way you've always wanted and a dedicated account Listen to your feedback to enhance and improve upon the long-standing challenges of an adjuster Work toward reducing and eliminating all the administrative work from an adjuster role Foster a culture of empathy, transparency, and empowerment in a remote-first environment At Reserv, we value diversity in backgrounds, perspectives, and life experiences and believe that diversity in viewpoints and critical thinking drives innovation, first-principles thinking, and success. We welcome applicants from all backgrounds and encourage those from all walks of life to apply. If you believe you are a good fit for this role, we would love to hear from you!

PROVIDER AUDIT AND REIMBURSEMENT LEAD AUDITOR (CMS) - REMOTE ARC Group has an immediate opportunity for a Provider Audit and Reimbursement Lead Auditor (CMS)! This position is 100% remote working eastern time zone business hours. This is a direct hire FTE position and a fantastic opportunity to join a well-respected organization offering tremendous career growth potential. 100% REMOTE! Candidates must currently have PERMANENT US work authorization. Job Description: The Provider Audit and Reimbursement Lead utilizes advanced knowledge of Medicare laws, regulations, instructions from the Centers for Medicare and Medicaid Services (CMS), and provider policies to perform desk reviews and audits of the annual Medicare cost reports, as well as interim rate review/reimbursement, and/or settlement acceptance/finalization for all provider types, including complex and organ transplant hospitals, as both a preparer and reviewer of work product based on established performance goals. The position will mentor and train Auditors and In-Charge Auditors and oversee daily workload of unit team. ESSENTIAL DUTIES & RESPONSIBILITIES Lead Accountabilities (60%): Coordinates with management by overseeing the unit's daily workload. Routinely uses independent judgment and discretion to make decisions for self and less experienced auditors with regard to additional time and procedures; identifies and raises errors to the attention of supervisor and/or provider and identifies and communicates actions to correct same. Prioritizes auditor work and ensures that audit work is completed on time. Recognizes data needs for self and other auditors; develops plan of work for less experienced auditors (10%) Analyzes working papers and cost reports for errors. (10%) Reviews workpapers of auditors for correctness, control and adherence to Generally Accepted Accounting Practices (GAAP), Generally Accepted Accounting Standards (GAAS) and Government Auditing Standards (GAS) as required. Examines and reviews workpapers upon completion of the audit to ensure compliance with CMS Uniform Desk Review (UDR), policy, or technical direction and reflects proper reference, clear and concise conclusion of the major audit categories and assembly of working papers into logical sequence. (10%) Reviews, evaluates and approves the disbursement of tentative cost settlements in compliance with Federal and State Government regulations for each class/type of provider within area of responsibility. (5%) Develops technical competence and constructive work attitudes in self and less experienced auditors; strives to build an effective team and to develop the growth needs of individual members of his/her team. (10%) Coordinates the assignments and subsequent development of auditors based on their training needs; explains work to be performed and principle or objective of procedure; provides accurate and constructive coaching, mentoring, and training of team members. Identifies training needs within the team and/or department. (5%) Manages, implements and coordinates an internal quality control program in conjunction with the Internal Quality Control (IQC) department and provides reasonable assurance that the Provider Audit and Reimbursement Department has established, as well as is following, adequate policies, procedures, and is following applicable auditing standards. (5%) Facilitates the development of Quality Management System (QMS) policies and procedures. (5%) Auditor Accountabilities (40%) Performs audit functions including those which are non-routine; keeps track of instructions for many projects simultaneously. Presents and defends adjustments and workpapers to provider with minimal consultation from manager. (10%) Coordinates large audits and/ or diverse audits independently while seeking help on truly unusual or major items. (10%) Uses professional communication techniques in own and auditor's work and in conclusions drawn from the work. (5%) Establishes and maintains constructive provider relations by demonstrating a professional approach, expressing positive corporate image. Advises providers on Medicare policy questions and directs other questions to responsible departments or personnel. (5%) Conducts entrance and exit conferences and meetings away from office as needed. (5%) Perform other duties as the manager may deem necessary (5%) REQUIRED QUALIFICATIONS Bachelors' degree or a combination of education and experience in disciplines such as auditing, accounting, analytics, finance or similar experience in lieu of a degree In addition to having a thorough understanding of the Medicare cost report, including the step-down method, the candidate must possess the required work experience to independently perform the duties of the position. To demonstrate the necessary experience, the candidate must have performed the following tasks at a sufficiently successful level to show understanding of the work, judgment, and the ability to perform these tasks independent of supervision, which is generally gained through 2.5 to 3 years of Medicare cost report auditing experience: A Uniform Desk Review (UDR) and an audit for a large or complex hospital, as the in-charge auditor A review of Medicare Bad Debts, inclusive of all relevant sample selection and testing according to CMS standards A review of DSH, inclusive of all relevant sample selection and testing according to CMS standards A review of IME/GME, inclusive of reviewing rotation schedules, bed count and all relevant testing according to CMS standards A review and appropriate approval of an audit's scope A supervisory review and approval of all work papers* Sample testing, transferring of testing to the audit adjustment report, and explaining the adjustments to a provider with the achievement of understanding by the provider* Assistance to audit management in the assignment and monitoring of workload, as well as leading junior team members Additionally: The auditor must display leadership skills by being integrally involved in junior auditor formal training or assisting on special projects, or have been a Subject Matter Expert (SME)* The auditor must be able to prepare workpapers according to CMS standards The auditor must have a good working knowledge of all applicable software applications The auditor must be able to serve as an effective mentor for less experienced staff The auditor must demonstrate engagement, commitment to departmental success, and professionalism by completing their work within prescribed deadlines, taking ownership of their work and setting an example for more junior auditors and staff by consistently and reliably working the time necessary to properly complete their duties, timely attending meetings, providing adequate notice to management and co-workers when unexpected issues arise, and ensuring work is properly covered in the auditor's absence. Demonstrated oral and written communications skills Demonstrated ability to exercise independent judgement and discretion Demonstrated attention to detail PREFERRED QUALIFICATIONS 3 to 4 years of Medicare cost report auditing experience Demonstrated work experience to independently perform: A review of Nursing & Allied Health Education (NAHE), inclusive of calculating the additional add-on payment and all relevant testing A review of Organ Acquisition costs, inclusive of all relevant testing Requirements This opportunity is open to remote work in the following approved states: AL, AR, FL, GA, ID, IN, IO, KS, KY, LA, MS, NE, NC, ND, OH, PA, SC, TN, TX, UT, WV, WI, WY. Specific counties and cities within these states may require further approval. In FL and PA in-office and hybrid work may also be available. Would you like to know more about our new opportunity? For immediate consideration, please send your resume directly to John Burke ******************** or apply online while viewing all of our open positions at ******************* ARC Group is a Forbes-ranked a top 20 recruiting and executive search firm working with clients nationwide to recruit the highest quality technical resources. We have achieved this by understanding both our candidate's and client's needs and goals and serving both with integrity and a shared desire to succeed. At ARC Group, we are committed to providing equal employment opportunities and fostering an inclusive work environment. We encourage applications from all qualified individuals regardless of race, ethnicity, religion, gender identity, sexual orientation, age, disability, or any other protected status. If you require accommodations during the recruitment process, please let us know. Position is offered with no fee to candidate.

Through our dedicated associates, Arsenault delivers mission-critical services and solutions on behalf of Fortune 100 companies and over 500 governments creating exceptional outcomes for our clients and the millions of people who count on them. You have an opportunity to personally thrive, make a difference and be part of a culture where individuality is noticed and valued every day. Remote Data Entry Associate Equipment Provided Temp with chance to convert to full time Salary: $15-$20 HR. Hours: 8:00 am to 4:30 pm EST, M-F Would you enjoy being part of a team that makes a difference in people's lives Do you love helping people solve complex problems and delivering solutions? About The Role As a member of the team, you will be processing FSA and HSA claims. You will review and research the claim and process them on a web-based application. It is essential to have a good understanding of EOBs, FSAs, how to read receipts, doctor bills, and basic medical paperwork.We have 3 different classes with the 1st one starting in early October. A successful candidate will be computer literate, maintain good attendance, and have the right attitude and discipline to work from home. You will take pride in being a contributing member of a busy team. Meet your quality and volume requirements consistently. This starts as temporary position. You will receive fully paid training of 4-6 weeks. Based on performance and attendance you may be converted to a permanent employee with benefits. What You Will Be Doing Review and research claims Determine if the claim is valid to approve Process claims on a web-based application Completes assignments using multiple source documents to verify data or use additional information to do the work. Follows up on pending documents involving analysis. Requirements Be computer literate able to set up equipment and operate with ease Have own highspeed internet connection: 25 download and 5 upload Must be at least 18 years of age or older. Must have a high school diploma or general education degree (GED). Must be eligible to work in the Los Angeles, CA. Must be able to clear a criminal background check and drug test. Arsenault is an Equal Opportunity Employer and considers applicants for all positions without regard to race, color, creed, religion, ancestry, national origin, age, gender identity, gender expression, sex/gender, marital status, sexual orientation, physical or mental disability, medical condition, use of a guide dog or service animal, military/veteran status, citizenship status, basis of genetic information, or any other group protected by law.

We are the leading provider of professional services to the middle market globally, our purpose is to instill confidence in a world of change, empowering our clients and people to realize their full potential. Our exceptional people are the key to our unrivaled, culture and talent experience and our ability to be compelling to our clients. You'll find an environment that inspires and empowers you to thrive both personally and professionally. There's no one like you and that's why there's nowhere like RSM. The Position As a supervisor in RSM's growing Risk and Controls Practice, you will have the opportunity to draw from your experience and knowledge while continuing to grow your leadership skills through a high degree of client and industry exposure, career development and mentorship opportunities, and a diverse and inclusive culture. The fast-paced and dynamic environment in which we operate will provide you with daily challenges and exciting opportunities. In the Risk and Controls Practice we frequently work as or alongside a client's internal audit function, the chief risk officer or risk function, and various other members of management tasked with managing risk. Our advisors help our clients with identifying and prioritizing risk and leveraging process and controls to reduce risk exposure. Key Responsibilities Contributions to Firm Culture Model the core RSM values of respect, integrity, teamwork, excellence and stewardship in all interactions with clients and team members Lead teams in identifying out of the box solutions to complex issues. Encourage innovative thinking from seniors and associates Support RSM's goals around diversity and inclusion by nurturing an environment that understands individuality, promotes authenticity, and values varied perspective in arriving at solutions Client Experience Learn about the industry that we serve and leverage your understanding to become your clients' trusted advisor Identify current and relevant industry thought leadership and incorporate this into client service Independently implement and coach others on foundational industry policies, procedures, and work-programs Own process level client relationships and collaboration with external stakeholders Lead risk assessment management interviews and internal audit plan development Draft test plans or work programs for review by senior members of the team Create/review narratives or flowcharts for a process Identify and review all risks and controls for a process as needed Perform review of staff work for accuracy, completeness, and well-reasoned conclusions Manage budgets and provide accurate analysis of estimates to complete to engagement leader Prepare deliverable drafts Have the ability to support multiple client projects simultaneously, while actively contributing to other firm initiatives Participate in relevant industry associations and events to develop and/or maintain industry focus and relationships Talent Experience Encourage colleagues to think creatively, strive for growth through development opportunities, and maximize results while working within a team environment Proactively seek out opportunities to learn from or teach team members, build a coaching/mentoring network and take advantage of training opportunities to continually expand skills and demonstrate leadership capability Maintain willingness to give and receive candid feedback in both written and verbal form. Commit to self-development in response to constructive feedback received. Provide assistance, guidance, mentoring and feedback to staff assigned to work with you Support recruiting efforts by understanding and promoting the RSM brand and developing the ability to accurately assess talent Business Development Actively participate in relevant industry associations and events Demonstrate industry understanding and provide thought leadership to clients and prospects Build an internal network and actively demonstrate familiarity with other services provided by the firm Contribute to new pursuits by teaming and developing proposals and other materials Identify new client opportunities or surface ideas for introducing others to existing client relationships Position Required Qualifications Bachelor's or Master's Degree in business, accounting or related discipline. Minimum of 4 years of experience in audit, internal audit or related internal control positions Preferred Qualifications Proficiency in professional writing, spreadsheet, and presentation creation tools Job relevant certification (e.g. CPA, CIA) preferred Ability to travel to meet client needs and work collaboratively with others in-person and remotely Openness to workday flexibility, agility, remote work environment, leveraging new tools Effective communication skills, both verbally and in writing Effective time management and prioritization skills At RSM, we offer a competitive benefits and compensation package for all our people. We offer flexibility in your schedule, empowering you to balance life's demands, while also maintaining your ability to serve clients. Learn more about our total rewards at ************************************************** All applicants will receive consideration for employment as RSM does not tolerate discrimination and/or harassment based on race; color; creed; sincerely held religious beliefs, practices or observances; sex (including pregnancy or disabilities related to nursing); gender; sexual orientation; HIV Status; national origin; ancestry; familial or marital status; age; physical or mental disability; citizenship; political affiliation; medical condition (including family and medical leave); domestic violence victim status; past, current or prospective service in the US uniformed service; US Military/Veteran status; pre-disposing genetic characteristics or any other characteristic protected under applicable federal, state or local law. Accommodation for applicants with disabilities is available upon request in connection with the recruitment process and/or employment/partnership. RSM is committed to providing equal opportunity and reasonable accommodation for people with disabilities. If you require a reasonable accommodation to complete an application, interview, or otherwise participate in the recruiting process, please call us at ************ or send us an email at *****************. RSM does not intend to hire entry level candidates who will require sponsorship now OR in the future (i.e. F-1 visa holders). If you are a recent U.S. college / university graduate possessing 1-2 years of progressive and relevant work experience in a same or similar role to the one for which you are applying, excluding internships, you may be eligible for hire as an experienced associate. RSM will consider for employment qualified applicants with arrest or conviction records in accordance with the requirements of applicable law, including but not limited to, the California Fair Chance Act, the Los Angeles Fair Chance Initiative for Hiring Ordinance, the Los Angeles County Fair Chance Ordinance for Employers, and the San Francisco Fair Chance Ordinance. For additional information regarding RSM's background check process, including information about job duties that necessitate the use of one or more types of background checks, click here. At RSM, an employee's pay at any point in their career is intended to reflect their experiences, performance, and skills for their current role. The salary range (or starting rate for interns and associates) for this role represents numerous factors considered in the hiring decisions including, but not limited to, education, skills, work experience, certifications, location, etc. As such, pay for the successful candidate(s) could fall anywhere within the stated range. Compensation Range: $88,900 - $168,300 Individuals selected for this role will be eligible for a discretionary bonus based on firm and individual performance.

Hospital Compliance Auditor - (10032671) Description Join the transformative team at City of Hope, where we're changing lives and making a real difference in the fight against cancer, diabetes, and other life-threatening illnesses. City of Hope's growing national system includes its Los Angeles campus, a network of clinical care locations across Southern California, a new cancer center in Orange County, California, and treatment facilities in Atlanta, Chicago, and Phoenix. our dedicated and compassionate employees are driven by a common mission: To deliver the cures of tomorrow to the people who need them today. The Hospital Compliance Auditor conducts audits systemwide to determine organizational integrity within the Hospital Compliance Program and reviews hospital and provider-based site practices and procedures to ensure they adhere to all relevant healthcare regulations and laws. Audits to evaluate systems, charge capture, and hospital billing including detection and correction of documentation, coding, and billing errors and/or medical necessity of services billed. The Hospital Compliance Auditor evaluates the adequacy and effectiveness of controls designed to ensure that processes and practices lead to appropriate execution of regulatory requirements and federal and state regulations and guidelines, CMS and other third-party payor billing rules, and OIG compliance standards. The Hospital Compliance Auditor serves as an institutional subject matter expert and authoritative resource on auditing and monitoring practices and interpretation and application of documentation and coding rules and regulations, and medical necessity of services delivered. This position sits within the Healthcare Regulatory and Reimbursement Compliance vertical of the Ethics & Compliance program, is a member of the Hospital Compliance team, and reports to the System Manager, Hospital Compliance. As a successful candidate, you will: Implements and manages a comprehensive systemwide proactive annual audit plan for the Hospital Compliance Program with focus on high-risk areas. Plans and performs hospital compliance related systems, revenue cycle, charge capture and claims audits, including accuracy and adequacy of documentation and coding related to hospital billing and/or medical necessity reviews. Initiates and manages auditing and monitoring as needed in conjunction with investigations and inquiries and assists with corrective action plans. Conducts analysis to identify inappropriate hospital billing and coding practices, identify and report compliance issues and concerns in addition to the claims and financial impact. Makes recommendations for corrective action. Distills and summarizes complex audit findings into digestible education and action items for stakeholders. Prepares written reports of audit findings and recommendations and presents to appropriate stakeholders; evaluates the adequacy of management corrective action to improve deficiencies; maintains audit records. Assists in validating accuracy of external audits, utilization management reporting, and other inquiries. Assists departmental management with the development of tools, templates, and process improvement recommendations. Assists in documentation and internal evaluation of Ethics & Compliance Program effectiveness consistent with professional standards. Understands where regulatory guidance and hospital policies and procedures might intersect in terms of compliant billing and coding, provide customer feedback to guide their decision making. In conjunction with department manager, provides education and feedback to stakeholders when audit deficiencies are identified. Stays current with Medicare, Medicaid and other third party rules and regulations, CPT, ICD10 coding updates and enhances professional growth and development by participating in educational programs relating to such topics. Serves as a system resource to answer billing appropriateness questions and those arising from audits, including government audits. Maintains knowledge of City of Hope Provider billing and collection systems, including knowledge of report writing capability, and works with Information Systems personnel to identify and request data needed for audits. Qualifications Your qualifications should include: Bachelor's degree; 3 additional years of experience plus the minimum experience requirement may substitute for minimum education.Seven (7) years auditing and coding experience.Certified Coding Specialist (CCS) and/or AHIMA, AAPC or other equivalent recognized coding certification required City of Hope employees pay is based on the following criteria: work experience, qualifications, and work location.City of Hope is an equal opportunity employer. To learn more about our Comprehensive Benefits, please CLICK HERE. #LI-RA Primary Location: US-Nationwide-USA-Remote-US-RemoteJob: Compliance AdministrationWork Force Type: RemoteShift: DaysJob Posting: Nov 25, 2025Minimum Hourly Rate ($): 46.580100Maximum Hourly Rate ($): 74.528200

Insight Assurance is a global audit firm on a mission to transform how organizations achieve cybersecurity and compliance. Founded by former Big 4 (EY) professionals, we deliver next-generation audit services across SOC 2, ISO 27001, PCI DSS (QSA), HITRUST, CMMC (C3PAO), and FedRAMP (3PAO) frameworks. We're not your traditional audit firm - we're tech-enabled, leveraging compliance automation and advanced collaboration tools to make audits faster, smarter, and more impactful for our clients. Recognized on the Inc. 5000 and Fast 50 lists, Insight Assurance is one of the fastest-growing global audit firms, with 170+ professionals supporting nearly 2,000 clients across the Americas, EMEA, and APAC. JOB PURPOSE We are seeking a highly skilled compliance auditor who has secured their CMMC Certified Professional (CCP) certification or would be able to secure their CCP within six months, to join our secure team which assesses client's ability to safeguard government data. The ideal candidate will have demonstrated experience leading compliance initiatives in regulated environments, ensuring adherence to complex regulatory frameworks, and knowledge of CMMC and NIST. Due to the legal requirement of this role, applicants must hold full or dual citizenship in the U.S., Australia, a NATO member country*(listed below), or South Korea, and be able to produce a valid passport. Strong analytical, communication, and collaboration skills are essential to successfully work within our cross-functional teams and with external clients. This is a unique opportunity to make a meaningful impact on data security while working in a dynamic, fast-paced, high-stakes environment. DUTIES AND RESPONSIBILITIES Assessment Planning: Develop a comprehensive assessment plan outlining the scope, objectives, and methodology for evaluating the organization's cybersecurity practices and controls. Evaluate Compliance: Assess the organization's adherence to the HITRUST and CMMC frameworks by reviewing policies, procedures, and technical security controls to ensure they meet the required maturity level. Data Collection: Gather and analyze relevant documentation, including system configurations, security policies, incident response plans, and training materials. Conduct Interviews: Engage with key personnel within the organization to understand the implementation of cybersecurity practices and gauge their familiarity with security protocols. Risk Assessment: Identify potential risks and vulnerabilities in the organization's cybersecurity posture, determining their potential impact on safeguarding governmental data. Reporting Findings: Create detailed reports that document assessment findings, highlighting areas of compliance and non-compliance, along with recommendations for improvement. Provide Guidance: Offer expert advice and best practices to help organizations enhance their cybersecurity measures and achieve compliance with HITRUST and CMMC requirements. Follow-Up Assessments: Conduct follow-up assessments to verify that corrective actions have been implemented, and that the organization is on track to achieve or maintain compliance. Continuous Learning: Stay updated on changes in the HITRUST and CMMC frameworks, cybersecurity threats, and mitigation strategies to provide the most relevant and effective assessments. Client Interaction: Maintain clear communication with clients throughout the assessment process to ensure understanding and facilitate collaboration. SPECIFIC DUTIES Assist the Lead assessor in gathering and evaluating assessment evidence. Evaluates the design and effectiveness of controls. Identifies and communicates preliminary assessment findings for daily checkpoint meetings. Foster stakeholder relationships through proactive communication with clients, colleagues and partners. Proactively communicate with management regarding any potential issues. SKILLS Excellent oral and written communication skills. Ability to work individually as well as collaboratively. A high degree of motivation. Fluency in English is required. EDUCATION Bachelor's degree in accounting, business, cyber security, or management information systems. EXPERIENCE At least 3 years of experience performing IT audit engagements at a Big 4 or other audit/consulting firm. Experience using GRC and compliance automation tools (Vanta, Drata, SecureFrame) is a plus. TRAINING AND CERTIFICATIONS Candidates with an active or working towards RP, RPA, or CCP certification. The ideal client will already possess a CISA, CPA, or CISSP certification. As part of this role, you will also be required to complete CMMC training within your first 6 months. Once Tier 3 suitability has been achieved, participation with the CMMC service line will be expected. A candidate on a path to secure a CMMC certification within six months must possess an approved Intermediate Certification, such as: (ISC)2 CGRC/CAP CompTIA CASP+ CompTIA Cloud+ CompTIA PenTest+ CompTIA Security+ GIAC GSEC BENEFITS Flexible Paid Time Off and paid Holidays Quarterly Performance Bonuses 100% Remote Competitive salary and benefits package. Opportunities for professional growth and development. Collaborative and innovative work environment. Insight Assurance is an equal-opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. *NATO Country Listing: Australia Barbados Belgium British Virgin Islands Canada Croatia Czech Republic Denmark Estonia Finland France Germany Greece Hungary Iceland Italy Latvia Lithuania Luxembourg Montenegro Netherlands Norway Poland Portugal Romania Slovakia Slovenia South Korea Spain Sweden Turkey US Virgin Islands United Kingdom United States Privacy Notice CCPA: Insight Assurance shares your personal data/information with Greenhouse recruiting because this is the tool we use for the recruitment process. Insight Assurance does not sell personal data/information under any circumstances. You may exercise your rights under personal data protection legislation by reaching out to us via: *********************** or submit a request via mail at 400 N Tampa St. 15th Floor Suite 129, Tampa, FL 33602 Privacy Notice GDPR: This notice informs you about the categories of Personal Data/ Information and the Purpose and Scope of Processing Activities to be undertaken by Insight Assurance (we, us, our), under its job application and recruitment process. We resort to Greenhouse.com as the platform that supports our recruitment process, and therefore your Personal Data/ Information will be Processed on this tool (hosted, shared with, cross-referenced, accessed by our team); we have in place contractual terms and the commitment of Greenhouse.com that ensures the Security and Confidentiality plus Purpose limitation with regards to the Processing of your Personal Data. When you reply to one of your job postings, you voluntarily and freely submit your Personal Data to us; this, allied with the fact that the Processing by us (and over Greenhouse.com) of that Personal Data has the sole Purpose of validating your application and proceeding with the inherent scrutiny and decision, allows us to argue having Legitimate Interest as the applicable Legal Basis to undertake the Processing of your Personal Data under this scope. We are a U.S. based company, hence some or all Personal Data pertaining to you will be hosted in the U.S. The categories of Personal Data under Processing consist of: Identification Contact Education and Professional Interview performance Evaluation You may exercise several Rights as determined under applicable Personal Data Protection legislation, in short: Right of Access - meaning getting information about the Personal Data under Processing by us, except for the information you already know; Right of Erasure - you may ask for us to erase all Personal Data pertaining to you under Processing; this may imply you being excluded from the recruitment process, for without information we cannot proceed with it; Right of Opposition or Restriction of Processing - you may ask us to stop some Processing or restrict the Processing of some Personal Data, this may imply you being excluded from the recruitment process, at our sole discretion also for without information we cannot proceed with it; Rectification - you can rectify your Personal Data at anytime

It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances. Job Summary: The Coding and Compliance Auditor- Behavioral Health performs complex review and adjustments of medical claims to ensure accuracy in claim payments. This is accomplished through data analysis to ensure alignment with payment policies, medical policies, correct coding, and state and federal regulatory requirements. Our Investment in You: · Full-time remote work · Competitive salaries · Excellent benefits Key Functions/Responsibilities: · Performs operational and financial audits of provider claims to identify overpayments and inform resolution of root cause issues with system configuration, provider contracts, claims operations, provider billing accuracy, and other party liability processes · Adjusts claim payments and adjudicates claims following established recovery guidelines and job aides · Identifies potential recovery projects and reports findings to management · Achieves department production, quality requirements, and individual financial recovery goals · Participates in special projects and initiatives · Assists in developing/revising departmental policies and procedures · Attends and participates in team meetings · Mentors and coaches less experienced staff and new hires Supervision Exercised: · None Supervision Received: · Direct supervision is received weekly Qualifications: Education Required: · Bachelor's Degree or equivalent combination of education, training and related experience required. Experience Required: · 5 + years of work experience in Behavioral Health claims processing and/or health insurance experience working at a Behavioral Health facility or practice. This also includes at least 3 years of work related to medical billing and coding Experience Preferred/Desirable: · Claim audit experience, (Behavioral Health Claims experience desirable) · Prior Medicaid/Medicare exposure · Working knowledge of Facets · SQL training Required Licensure, Certification or Conditions of Employment: · CPC or CCS certification preferred · Successful completion of pre-employment background check Competencies, Skills, and Attributes: · Intermediate to expert knowledge of medical terminology, CPT, ICD9, HCPCS coding is required · Ability to work within large datasets to identify errors, anomalies, and outliers · Works with a high level of accuracy, attention to detail, and with superb work quality · Strong oral and written communication skills; ability to interact effectively with both internal WellSense colleagues as well as with external constituents such as providers and suppliers · Intermediate Excel experience required as well as proficiency using other Microsoft Office products including Word, Outlook, and PowerPoint · Must be able to multi-task, prioritize projects and work well with deadlines Working Conditions and Physical Effort: · Regular and reliable attendance is an essential function of the position · Work is performed in a remote, work from home environment · Ability to work at a computer for entire work shift · No or very limited physical effort required. No or very limited exposure to physical risk About WellSense WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

This position is responsible for conducting coding audits, communicating results and recommendations to providers, management, and executive administration, and providing training and education to providers and ancillary staff. This position will support the implementation of changes to the CPT, CDT, HCPCS and ICD‐10 codes on an annual basis. Responsibilities Essential Duties: * Conduct prospective and retrospective chart reviews (i.e. baseline, routine periodic, monitoring, and focused) comparing medical and/or dental record notes to reported CDT, CPT, HCPCS, and ICD codes with consideration of applicable FQHC and payer/title/grant coding requirements.• Identify coding discrepancies and formulate suggestions for improvement.• Communicate audit results/findings to providers and/or ancillary staff and share improvement ideas.• Work with the Office of the CMO and provider leadership to identify and assist providers with coding.• Report findings and recommendations to Compliance Officer or designee, management, and executive leadership.• Provide continuing education to providers and ancillary staff on CDT, CPT, HCPCS, and ICD-10 coding.• Support compliance policies with government (Medicare& Medicaid) and private payer regulations.• Perform research as needed to ensure organizational compliance with all applicable coding and diagnostic guidelines.• Maintain professional and technical knowledge by attending educational workshops and reviewing professional publications.• Work closely with all departments, including but not limited to, Clinical Services, Nursing, Practice Leadership, Finance, IT, Training, and Billing to assist in accuracy of reported services and with chart reviews, as requested.• Work with the Purchasing department to order and distribute annual coding materials for all clinical sites and departments.• Assist Director of Compliance with incidents and investigations involving coding and/or documentation.• Work closely with all other Compliance personnel to provide coding/compliance support.• Advise Compliance Officer or designee of government coding and billing guidelines and regulatory updates.• Provide training to billing coding staff on coding compliance.• Participate in special projects and performs other duties as assigned.Knowledge/Skills/Abilities:• Proficiency in correct application of CPT, CDT, HCPCS procedure, and ICD‐10‐CM diagnosis codes used for coding and billing for medical claims.• Knowledge in correct application of SNOMED, SNODENT, and LOINC.• Knowledge of medical terminology, disease processes, and pharmacology.• Strong attention to detail and accuracy.• Excellent verbal, written, and communication skills.• Excellent organizational skills.• Ability to multi‐task.• Proficient in Microsoft Office Suite.• Critical thinking/problem solving.• Ability to provide data and recommend process improvement practices. Qualifications MINIMUM EDUCATION: High school diploma or equivalent. MINIMUM EXPERIENCE: 5 years of healthcare experience4 years of procedural and diagnostic coding REQUIRED CERTIFICATIONS/LICENSURE: UPON HIRE AAPC Certified Professional Coder (CPC) certification ORCertified Coding Specialist (CCS) certification through American Health Information Management Association (AHIMA)

What you can expect! Find joy in serving others with IEHP! We welcome you to join us in "healing and inspiring the human spirit" and to pivot from a "job" opportunity to an authentic experience! Under the direction of the Claims Production Manager and Supervisor, the Claims Processor Level II will be processing outpatient professional and institutional claims. This includes but is not limited to; lab, radiology, ambulance, behavior health, outpatient COB, dialysis, oncology/chemo, hospital exclusions etc., in an accurate and expedient manner. Commitment to Quality: The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. * Competitive salary * Telecommute schedule * State of the art fitness center on-site * Medical Insurance with Dental and Vision * Life, short-term, and long-term disability options * Career advancement opportunities and professional development * Wellness programs that promote a healthy work-life balance * Flexible Spending Account - Health Care/Childcare * CalPERS retirement * 457(b) option with a contribution match * Paid life insurance for employees * Pet care insurance Education & Requirements * Minimum of two (2) years of experience adjudicating outpatient professional and/or institutional claims preferably in an HMO or Managed Care setting * Processing of Medicare, Medi-Cal, or Commercial claims required * Proficient in rate applications for Medi-Cal and/or Medicare pricers * High school diploma or GED required Key Qualifications * ICD-9 and CPT coding and general practices of claims processing * Prefer knowledge of capitated managed care environment * Microcomputer skills, proficiency in Windows applications preferred * Excellent communication and interpersonal skills, strong organizational skills * Professional demeanor * Must be computer literate, maintain good attendance, and have the right attitude and discipline to work from home Start your journey towards a thriving future with IEHP and apply TODAY! Pay Range * $23.98 USD Hourly - $30.57 USD Hourly

Job Description Reporting to the Director of Quality & Compliance, the Compliance & Quality Auditor is responsible for ongoing analysis and review of regulatory compliance in patient records. Please note: This is a remote position; however, candidates must currently reside in the state of Florida. EDUCATION AND QUALIFICATIONS: A bachelor's degree in a healthcare or data management related field or relevant experience Hospice experience A minimum of one year experience in one or more of the following fields: health data management, data analysis, auditing, or a closely related field Knowledge of Florida Hospice regulations and statues, Medicare conditions of participation and payment, and Joint Commission standards preferred. Knowledge of and experience with HQRP and HOPE preferred. ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES: Monitor, review, and/or audits patient charts or other data for compliance with regulatory Provide staff feedback on audit corrections and observations with staff. Provides regular reports to management on patient chart compliance and various Conduct ad hoc reviews and audits based on high risk, problem prone, or otherwise specified Maintain tools, reports, data, metrics, benchmarking, tracking, and trending patient and compliance data. Participate in various committees to address risks and opportunities for improvement, to report on compliance data, and collaborate in process improvement SKILLS AND COMPETENCIES: Knowledge of compliance with all regulatory agencies governing health care delivery and the rules of accrediting Knowledge of Florida statutes and regulations, Conditions of Participation and Payment, and the Joint Commission Home Care Chapter. Ability to accurately and efficiently monitor and documented compliance and opportunities for improvement in patient charts. Ability to manage multiple priorities simultaneously and effectively handle the emotional stress of the workload. Ability to work independently, exercise confidentiality, discretion, and independent Ability to work in collaboration with other disciplines within the