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Claims auditor Jobs in Houston, TX

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Claims auditor • houston tx

Last updated: 16 hours ago

Medical Compliance Auditor

Texas Childrens HospitalBellaire, TX, United States
Full-time

We are searching for a Medical Compliance Auditor - someone who works well in a fast-paced setting.In this position, you will review and approve or deny medical claim appeals and perform clinical a... Show more

 • Promoted

Night Auditor

Holiday Inn Express & Suites Houston IAHHouston, TX, USA
$13.00 hourly
Full-time +1
Quick Apply

Sincere Hospitality is actively hiring for a Night Auditor.We are dedicated to fostering a culture of care, respect, and genuine hospitality that embraces our guests, team members, and the communit... Show more

Operational Auditor (1833)

Aramco Services CompanyHouston, TX, United States
Full-time

This position acts as the in-charge auditor on medium-size internal audits or as assistant to Auditor I on large, complex internal auditing assignments.Audits are directed at reviewing internal con... Show more

Staff Auditor

Search ServicesHouston, TX, US
Full-time
Quick Apply

Our Client is a boutique, well-respected CPA firm located in central Houston.With a diverse mid-market client base spanning multiple industries, the firm provides audit, tax, advisory, and M&A ... Show more

Premium Auditor / Senior Premium Auditor - Virtual

Texas MutualHouston, TX, United States
$37.02 hourly
Full-time

Texas Mutual is deeply committed to creating and maintaining an environment of mutual respect and is proud to be an equal opportunity employer.All qualified applicants are encouraged to apply and w... Show more

Auditor

TradeJobsWorkForce77253 Houston, TX, US
Full-time

Auditor Job Duties: Ensures compliance with established internal control pr... Show more

 • Promoted

Auditor II

Service Corporation InternationalHouston, TX, United States
Full-time

Performs detailed operational, SOX compliance, financial audits.Gathers substantive data from accounting records, operational reports, interviews with company/department personnel and observations.... Show more

IT Auditor

Diverse LynxHouston, TX, United States
Full-time

Must Have Technical/Functional Skills:.IT Audit, ITGC, SOX Compliance, ISO 27001 (ISMS), Risk & Compliance, Control Testing, Audit Governance, Stakeholder Management.Act as Senior IT Audit Lead res... Show more

Night Auditor

Crestline Hotels and ResortsHouston, Texas, United States, 77056
Full-time

The Front Desk Night Clerk will serve as ambassador to the hotel handling all check-in and check-outs, answering incoming calls while upholding Guest Service Standards.Functions will also include n... Show more

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Auditor Nocturno

Dalwadi Hospitality ManagementHouston, TX, US

El Auditor Nocturno sirve como el enlace principal con los huéspedes durante el turno de noche y son.Debe ser capaz de trabajar de forma independiente y con.Lo siguiente refleja los deberes esencia... Show more

IMS Auditor

IRQAHouston, TX, United States
Full-time

You'll perform business assurance assessments and recommend certification, deferral, suspension or withdrawal of certification in accordance with ISO 9001, ISO14001, and ISO45001 management system ... Show more

Night Auditor

TradeJobsWorkforce77061 Houston, TX, US
Full-time

Night Auditor Job Duties: Welcome guests in a warm and friendly manner overnight.Ascertains ... Show more

 • Promoted

Service Auditor

Briggs EquipmentHouston, TX, United States
Full-time

At Briggs Industrial Solutions, our team members and our culture are just as important to the company as serving our customers.We believe our team members are the key to our success and we pride ou... Show more

Senior Auditor

Det Norske VeritasHouston, TX, United States
$146,349.00 yearly
Full-time

DNV Business Assurance USA, Inc.Senior Auditor to work remotely out of our Houston, TX office with 80% domestic travel and up to 5% international travel to client sites.Certify quality management s... Show more

Warehouse Auditor

Capstone Logistics LLCHouston, TX, US
Full-time

Houston, TX $647 - $740/weekly 1st Shift: 5am until finished Monday - Friday People want to work at Capstone because of our high-performance culture.We build strong relationships, challenge the sta... Show more

 • Promoted

Staff Auditor - Senior Auditor - 2671

DXP EnterprisesHouston, TX, United States
Full-time

Staff Auditor - Senior Auditor.Staff / Senior Auditor to support the internal controls and SOX compliance functions.The Staff - Senior Auditor is responsible for performing risk assessments, perfor... Show more

Staff Auditor

Texas Department of TransportationHouston, TX, United States
$50,000.00 yearly
Full-time +1

TxDOT's Internal Audit Division is looking for an Auditor I, II or III based in Austin, Houston, Fort Worth, Childress, or Dallas to perform complex process audits.The ideal candidate is motivated ... Show more

QMS Auditor

Foxconn Industrial InternetHouston, TX, US
Full-time
Quick Apply

This position is responsible for supporting the Integrated Management System (IMS), process improvement plans, key metrics, and hosting internal and external audits.Analyze IMS System data, develop... Show more

Supervisory Auditor

US Government JobsHouston, TX, United States
Full-time

The Office of Inspector General (OIG) is an independent office whose mission is to promote excellence, integrity, and accountability throughout the Department of Homeland Security (DHS).In our dyna... Show more

Claims Manager

Apache Industrial ServicesHouston, TX, United States
Full-time

Position Reports To: Director Risk Management / General Counsel.Position Summary: Non-Supervisory role, supporting mitigation of the organization's exposure to risk by formulating, developing, and ... Show more

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Medical Compliance Auditor

Medical Compliance Auditor

Texas Childrens HospitalBellaire, TX, United States
6 days ago
Job type
  • Full-time
Job description
We are searching for a Medical Compliance Auditor - someone who works well in a fast-paced setting. In this position, you will review and approve or deny medical claim appeals and perform clinical audits of medical records submitted in support of services billed by providers. This process includes clinical judgment, utilization review, application of product benefits, understanding of regulatory requirements for Medicaid managed care and fraud and abuse, and verification of medical necessity utilizing nationally recognized criteria.

Think you've got what it takes?

Job Duties & Responsibilities
• Assess the treatment plan, clinical information, and medical necessity of all requested services
• Utilizes established criteria to appropriately review billed services within established timeframe required.
• Consults with medical directors and clinical staff regarding patient's history and current care needs and whether services billed were appropriate.
• Refers case failing medical necessity criteria to the Special Investigations Unit (SIU) Director and SIU Workgroup for review and a recommendation for action.
• Telephonic follow-up with the provider's office to request additional information as needed.
• Completes timely entry of information into electronic file including a chart with detailed findings of the review and a report summarizing the results of the audit.
• Evaluate benefit coverage and regulatory guidelines pertinent to decision making for each investigation.
• Perform Clinical and Coding Review on Medical Claim Appeals.
• Assess and process all education and recoupment letters after Special Investigative Committee review decision.
• Facilitates provider communication and education.
• Liaisons with internal staff members.
• Perform Clinical Review and make recommendation on Audit Pass/Fail.
• Ongoing assessment for quality indicators and concerns.

Skills & Requirements
• Required Associate's Degree in Nursing or
• Technical Diploma in Vocation Nursing
• Preferred Bachelor's Degree in Nursing
• Required LVN - Lic- Licensed Vocational Nurses Texas Board of Nursing or Nursing Licensure Compact or
• RN-Lic-Registered Nurses Texas Board of Nursing or Nursing Licensure Compact
• Preferred CPC-Cert-Cert Professional Coder Americal Academy of Professional Coders
• Required 3 years Clinical experience in the applicable field according to the license (LVN or RN)
• 4 years of Medical Auditing experience.

ABOUT US

Founded in 1996, Texas Children's Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.

To join our community of 15,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities.

Texas Children's is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.