claims auditor

EXL Service

<div><p>Job Description: The Provider Touch Specialist will be responsible for managing provider relations and service interactions within their assigned team. Acting as a key liaison, this individual will support external providers with audit inquiries, claims reimbursement progress, and training on portal navigation and service enhancements. The role also involves guiding providers on claim audit record submissions, timelines, and process adherence.
</p><p>The ideal candidate will be adept at identifying operational gaps, resolving complex claims issues, and effectively communicating solutions. This role is critical in fostering and maintaining strong relationships between EXL and our valued providers while ensuring exceptional service and satisfaction.
</p><p><b>Salary Range: $65,000 &ndash; $80,000 </b><i>(based on experience, skills, and qualifications)
</i><br>
<b>Location: 100% Remote (U.S.-based)
</b></p><p><b>Up to 10% annual travel </b><i>(for team meetings and limited client onsite engagements.)
</i></p><p><b>For more information on benefits and what we offer please visit us at </b><b>https://www.exlservice.com/us-careers-and-benefits
</b></p><p>The posted range is the hiring range for this role &mdash; a subset of the broader range available to employees over time &mdash; and reflects base salary across our national hiring scale. Final offers are based on several factors, including the candidate's skills and experience, internal pay equity, work location, market conditions for the role, and the specific scope and responsibilities of the position. The top of the range is reserved for candidates who notably exceed the requirements; the lower end applies to those with less experience or fewer preferred qualifications. For positions based in higher-cost zones (e.g., California, New York, New Jersey), actual compensation may exceed the posted range; your recruiter will share specifics during the process.</p></div>
<br><div><ul><li>Responsibilities: Serve as the primary contact for provider audit inquiries, claims reimbursement progress, and service-related concerns.
</li><li>Provide training and education on claims audit record submissions, timelines, and process guidelines.
</li><li>Assist providers in optimizing portal usage and understanding service enhancements.
</li><li>Identify and address operational inefficiencies while implementing data-driven solutions.
</li><li>Research and resolve complex claims issues, ensuring timely and effective communication of resolutions.
</li><li>Collaborate with internal teams to improve tools, resources, and provider support systems.
</li><li>Utilize business knowledge and sound judgment to navigate ambiguous situations and address non-standard requests.
</li><li>Build and maintain strong provider relationships, ensuring their needs are met while aligning with company policies.
</li><li>Contribute to the success of the Provider Touch Team by fostering collaboration and enhancing the overall provider experience.</li></ul></div>
<br><div><ul><li>Qualifications: 4+ years of experience in healthcare or managed care settings.
</li><li>3+ years of direct provider-facing experience.
</li><li>Intermediate knowledge of claims processing and auditing.
</li><li>Strong background in claims processing.
</li><li>Excellent verbal and written communication skills.
</li><li>Outstanding interpersonal skills with the ability to build rapport and maintain positive relationships.
</li><li>Strong customer service mindset with a solution-oriented approach.
</li><li>Solid understanding of healthcare operations and industry best practices.
</li><li>Proficiency in PC skills and data software applications.
</li></ul><p><b>What We Offer:
</b></p><p>At EXL, we provide a dynamic, fast-paced, and innovative environment where entrepreneurial professionals can make a significant impact.
</p><ul><li>Work closely with world-class healthcare consultants from day one.
</li><li>Gain exposure to various aspects of our clients' businesses while developing key teamwork and time-management skills.
</li><li>Benefit from our structured mentoring program, where junior employees receive guidance from senior professionals.
</li><li>Experience limitless growth opportunities within EXL and beyond.
</li><li>Comprehensive benefits package including Healthcare, Vision, Dental, and 401(k) options.
</li></ul><p><b>Join EXL Health and be part of a team that is redefining provider relations in the healthcare industry!
</b></p><p><b>Apply Today!</b></p></div>

Provider Touch Specialist

National General Insurance

<div><p>National General is a part of The Allstate Corporation, which means we have the same innovative drive that keeps us a step ahead of our customers&rsquo; evolving needs. We offer home, auto and accident and health insurance, as well as other specialty niche insurance products, through a large network of independent insurance agents, as well as directly to consumers.</p><p></p><p><b>
Job Description</b></p>
Responsible for creating or auditing a comprehensive estimate of damages for 1st and 3rd party material damage claims in either the auto or specialty lines leading to the proper disposition. Responsible for training, mentoring, controlling quality and providing technical assistance on material damage claims.<p></p><p>
National General Insurance is hiring a Field Auto Claims Adjuster in Rhode Island. In this role you will be responsible for preparing and/or auditing comprehensive damage estimates for first- and third-party material damage claims across Auto and Specialty lines, ensuring accurate evaluation and appropriate claim disposition. The ideal candidate brings strong experience in field-based auto damage estimating and is comfortable working independently in the field.</p><p></p><h3 class="jobSectionHeader"><b>
Key Responsibilities</b></h3><ul><li>Possesses strong estimating fundamentals in order to create or audit estimates of damages on 1st and 3rd party material damage losses of all severities</li><li>Possesses a deep understanding of the content of all policy types written by the company</li><li>Negotiates settlements, makes settlement payments and documents all activities in the most complex of files across multiple lines</li><li>Evaluates settlement alternatives by reviewing regulatory compliance and fair claims practices; makes decisions on best option</li><li>Builds mastered relationships with both internal and external customers across multiple lines</li></ul><p></p><p><b><br>
Skills</b></p>
Auto Insurance Claims, Business Acumen, Business Management, Claims Administration, Claims Resolution, Critical Thinking, Customer Service, Insurance Claims Investigations, Negotiation, Prioritization, Quality Management, Time Management, Training<p></p><p><b><br>
Compensation</b></p>
The base range offered for the role is:<br>
Field Auto NG NCL Consultant I: $26.49 - $37.50<br>
Field Auto NG NCL Consultant II: $28.03 - $39.42<br>
Field Auto NG NCL Senior Consultant I: $35.82 - $54.90<br>
<br>
And is based on experience and qualifications. Total compensation for this role is comprised of several factors, including the base compensation outlined above, plus incentive pay (i.e. commission, bonus, etc.) if applicable for the role.<p></p><p><b><br>
Joining our team isn&rsquo;t just a job &mdash; it&rsquo;s an opportunity. One that takes your skills and pushes them to the next level. One that encourages you to challenge the status quo. One where you can shape the future of protection while supporting causes that mean the most to you. Joining our team means being part of something bigger &ndash; a winning team making a meaningful impact.</b></p><p></p><p>
Effective July 1, 2014, under Indiana House Enrolled Act (HEA) 1242, it is against public policy of the State of Indiana and a discriminatory practice for an employer to discriminate against a prospective employee on the basis of status as a veteran by refusing to employ an applicant on the basis that they are a veteran of the armed forces of the United States, a member of the Indiana National Guard or a member of a reserve component.</p><p></p><p>
For jobs in San Francisco, please click &ldquo;here&rdquo; for information regarding the San Francisco Fair Chance Ordinance.</p><p><br>
For jobs in Los Angeles, please click &ldquo;here&rdquo; for information regarding the Los Angeles Fair Chance Initiative for Hiring Ordinance.</p><p></p><p>
To view the &ldquo;EEO Know Your Rights&rdquo; poster click &ldquo;here&rdquo;. This poster provides information concerning the laws and procedures for filing complaints of violations of the laws with the Office of Federal Contract Compliance Programs.</p><p></p><p>
To view the FMLA poster, click &ldquo;here&rdquo;. This poster summarizing the major provisions of the Family and Medical Leave Act (FMLA) and telling employees how to file a complaint.</p><p></p><p>
It is the Company&rsquo;s policy to employ the best qualified individuals available for all jobs. Therefore, any discriminatory action taken on account of an employee&rsquo;s ancestry, age, color, disability, genetic information, gender, gender identity, gender expression, sexual and reproductive health decision, marital status, medical condition, military or veteran status, national origin, race (include traits historically associated with race, including, but not limited to, hair texture and protective hairstyles), religion (including religious dress), sex, or sexual orientation that adversely affects an employee's terms or conditions of employment is prohibited. This policy applies to all aspects of the employment relationship, including, but not limited to, hiring, training, salary administration, promotion, job assignment, benefits, discipline, and separation of employment.</p><p></p><p>
National General Holdings Corp., a member of the Allstate family of companies, is headquartered in New York City. National General traces its roots to 1939, has a financial strength rating of A&ndash; (excellent) from A.M. Best, and provides personal and commercial automobile, homeowners, umbrella, recreational vehicle, motorcycle, supplemental health, and other niche insurance products. We are a specialty personal lines insurance holding company. Through our subsidiaries, we provide a variety of insurance products, including personal and commercial automobile, homeowners, umbrella, recreational vehicle, supplemental health, lender-placed and other niche insurance products.</p><p></p><p><b>
Companies &amp; Partners</b></p><p></p><p>
Direct General Auto &amp; Life, Personal Express Insurance, Century-National Insurance, ABC Insurance Agencies, NatGen Preferred, NatGen Premier, Seattle Specialty, National General Lender Services, ARS, RAC Insurance Partners, Mountain Valley Indemnity, New Jersey Skylands, Adirondack Insurance Exchange, VelaPoint, Quotit, HealthCompare, AHCP, NHIC, Healthcare Solutions Team, North Star Marketing, Euro Accident.</p><p></p><p><b>
Benefits</b></p><p></p><p>
National General Holdings Corp. is an Equal Opportunity (EO) employer &ndash; Veterans/Disabled and other protected categories. All qualified applicants will receive consideration for employment regardless of any characteristic protected by law. Candidates must possess authorization to work in the United States, as it is not our practice to sponsor individuals for work visas. In the event you need assistance or accommodation in completing your online application, please contact NGIC main office by phone at (336) 435-2000.</p><p></p><p><br>
Allstate provides a comprehensive technology setup, including a laptop, monitors, headset, keyboard, and mouse. Employees eligible to work from home also receive a monthly connectivity reimbursement to help offset internet costs.</p><p></p><p><br>
When working from home, you must have a dedicated, private workspace free from distractions, along with appropriate desk and seating. Reliable internet is required, with minimum speeds of 50 MB download and 5 MB upload.</p></div>

Field Auto Claims Adjuster - National General

Centene

<div><p>You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you&rsquo;ll have access to competitive benefits including a fresh perspective on workplace flexibility.<br>
</p><p><b>Please note: this is a remote role with preference on candidates located in Texas.
</b></p><p><b>Position Purpose: </b>Investigate allegations of potential healthcare fraud and abuse activity. Assist in planning, organizing, and executing claims investigations or audits that identify, evaluate and measure potential healthcare fraud and abuse.</p><ul><li>
Conduct investigations of potential waste, abuse, and fraud</li><li>
Document activity on each case and refer issues to the appropriate party</li><li>
Perform data mining and analysis to detect aberrancies and outliers in claims</li><li>
Develop new queries and reports to detect potential waste, abuse, and fraud</li><li>
Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions</li><li>
Assist with complex allegations of healthcare fraud</li><li>
Prepare summary and/or detailed reports on investigative findings for referral to Federal and State agencies</li><li>
Complete various special projects and audits</li><li>
Performs other duties as assigned.</li><li>
Complies with all policies and standards.</li></ul><p><b>
Education/Experience:</b><br>
Bachelor's Degree Business, Criminal Justice, Healthcare, or related field, or equivalent experience required. 1+ years Medical claim investigation, medical claim audit, medical claim analysis, or fraud investigation required.</p>
Pay Range: $56,200.00 - $101,000.00 per year<p>
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.</p><p>
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.</p><p><br>
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act</p></div>

SIU Investigator

State of Arizona

<div><div><div><div><div><ul><li>541302
</li></ul></div><div><ul><li>PHOENIX
</li></ul></div><div><ul><li>INDUSTRIAL COMMISSION
</li></ul></div><div><ul><li>Full-time
</li></ul></div><div><ul><li>Closing at: Jun 16 2026 - 23:55 MST
</li></ul></div></div><p></p><div><div><h1 class="jobSectionHeader"><b>INDUSTRIAL COMMISSION</b></h1>
<h2 class="jobSectionHeader"><b><i>Are you ready to work for an exceptional state agency that works to protect the life, health, safety, and welfare of the employees in the State of Arizona? Apply with us! The Industrial Commission of Arizona (ICA) is committed to the highest standards of compliance, demonstrating leadership in all areas, and teaching and working with employers and employees to make them successful. A thriving workforce in Arizona is what we strive for and work towards each day.</i></b></h2>
</div><h3 class="jobSectionHeader"><b>W/C INSURANCE CLAIMS SPECIALIST 2</b></h3>
<div>Job Location:
</div><div><h4 class="jobSectionHeader"><b>Address: Claims Division/Compliance Section</b><br>
<b>800 W. Washington Street, Phoenix, AZ 85007</b></h4>
</div><div>Posting Details:
</div><div><h4 class="jobSectionHeader"><b>Salary: $17.05 - $17.60</b><br>
<b>
</b></h4><h4 class="jobSectionHeader"><b>Grade: 17</b><br>
<b>
</b></h4><h4 class="jobSectionHeader"><b>Closing Date: June 16, 2026</b></h4>
</div><div>Job Summary:
</div><div><p>This position is responsible to audit incoming claims documents for compliance with applicable workers compensation claims management laws, statutes, and case laws.</p>
<p><i>
This position may offer the ability to work remotely, within Arizona, based upon the department's business needs and continual meeting of expected performance measures.</i></p>
<p><i>
The State of Arizona strives for a work culture that affords employees flexibility, autonomy, and trust. Across our many agencies, boards, and commissions, many State employees participate in the State&rsquo;s Remote Work Program and are able to work remotely in their homes, in offices, and in hoteling spaces. All work, including remote work, should be performed within Arizona unless an exception is properly authorized in advance.</i></p>
</div>
<div>Job Duties:
</div><div><div>Essential Duties and Responsibilities include but are not limited to:<br>
<ul><li>This position will critically analyze submitted forms for compliance and issue appropriate awards when indicated.</li><li>Audit insurance carriers, self-insured employers and third-party administrators adjusting workers&rsquo; compensation claims.
</li><li>Reviews all notices, attached medical and/or documentation to verify it supports current change of status and/or calculation of wage and awards. After analysis, specialist will issue correct corresponding award, notification, or document.
</li><li>Answer incoming phone calls from injured workers, attorneys, interested parties, claim adjusters, medical providers, and the general public.
</li><li>Matches documents lacking information to existing Commission claims files by researching information in Claims database and for creating a new claim file for documents received when there is no existing claim file.</li><li>Provides backup assistance to data entry, error resolution, insurance or combine/delete, as requested and
</li><li>Participates in Arizona Management System (AMS) and daily Huddle board.</li><li>Attends staff meetings, seminars, conferences, training classes.</li></ul></div></div><br>
<div>
Knowledge, Skills &amp; Abilities (KSAs):
</div><div><div>Knowledge in<br>
<ul><li>Basic knowledge or ability to learn of applicable workers compensation claims management laws, statutes, and case laws.
</li><li>Basic Medical terminology.
</li><li>Microsoft Office Suite; Outlook, Word, Excel, Google Office Suite, Gmail, Sheets and Docs</li><li>Basic English</li><li>Basic Mathematics</li><li>The insurance industry claims adjusting standards and practices.
</li></ul><ul><li>Skill in:</li><li>Communicating verbally and in writing to resolve disputes with interested parties.
</li><li>Basic analysis of insurance, medical and legal documents.
</li><li>Reviewing and interpreting Arizona Workers' Compensation laws, rules, procedures, and court decisions</li><li>Critical thinking</li><li>Time Management</li><li>Initiative and attention to detail</li><li>Customer service</li><li>Organizing and planning</li><li>Basic Business process acumen, management skills including workflows and information management.
</li></ul><ul><li>Ability to:</li><li>Interpret medical records to determine physical limitations for injured workers.</li><li>Manage heavy workload with high level of accuracy and production.</li><li>Learn computer systems and applications.</li><li>Work well within a diverse and inclusive office environment.</li><li>Process documents in a timely manner and within established productivity standard.</li><li>Prioritizes work within established time frames.</li><li>Manage time effectively and meet deadlines.</li><li>Adapt to changing circumstances.</li><li>Demonstrate initiative and attention to detail.</li><li>Exercise discretion and judgment.</li><li>Works well under pressure.</li><li>Perform job responsibilities incorporating lean management and principles of the Arizona Management System.</li><li>Produce high quality, nearly error-free output.</li></ul></div></div><br>
<div>
Selective Preference(s):
</div><div><p>The ideal candidate for this position will have:<br>
Claims adjusting license, certification (WCCA, WCCP, CPCU) or designation relating to workers' compensation.</p><br>
</div>
<div>Pre-Employment Requirements:
</div><div><p><i>All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).</i></p>
</div>
<div>Benefits:
</div><div><p>The Arizona Department of Administration offers a comprehensive benefits package to include:
<br>
Sick leave<br>
Vacation with 10 paid holidays per year<br>
Health and dental insurance<br>
Retirement plan<br>
Life insurance and long-term disability insurance<br>
Optional employee benefits include short-term disability insurance, deferred compensation plans, and supplemental life insurance</p><br>
<p><i>
By providing the option of a full-time or part-time remote work schedule, employees enjoy improved work/life balance, report higher job satisfaction, and are more productive. Remote work is a management option and not an employee entitlement or right. An agency may terminate a remote work agreement at its discretion.</i></p>
<p><i>
For a complete list of benefits provided by The State of Arizona, please visit our </i><i>benefits page</i></p>
</div>
<div>Retirement:
</div><div><p>You will be eligible to participate in the state employee health/disability insurance plan, and you are required to participate in the Arizona State Retirement System (ASRS). ASRS participation may begin immediately or upon your 27th week of employment. Contributions are matched by the employer.</p>
</div>
<div>Contact Us:
</div><div><p>If you have any questions please feel free to call 602-542-5559 or email HR@azica.gov for assistance.</p></div></div></div></div></div>

W/C INSURANCE CLAIMS SPECIALIST 2

<div><p>You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you&rsquo;ll have access to competitive benefits including a fresh perspective on workplace flexibility.<br>
</p><p><b>***POSITION IS REMOTE NATIONWIDE***</b></p><p><b>
***CANDIDATE MUST HAVE 2+ YEARS FRAUD, WASTE AND ABUSE EXPERIENCE***</b></p><p><b>
Position Purpose:</b> Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, and pharmacies to include but not limited to physicians, inpatient, outpatient, ancillary, behavioral health care, laboratory, etc. Provides investigative support to the Special Investigations Unit (SIU) related to coding and billing issues and identifies potential overpayments and suspected health care fraud and abuse. Position requires the associate to verify authorization for services and written documentation of services provided against claim information, ensure the appropriateness and accuracy of diagnosis and procedure codes supporting such claims, coordinate medical necessity and appropriate level of care determinations with Medical Directors, and validate services against CMS and State-specific coverage, limitations and exclusion guidelines. Coordinate with internal and external resources in determining the appropriateness of codes found in administrative, medical, claim and financial records, develop reports of findings and recommendations, communicate complex results of audit findings in meetings and/or judicial hearings, and assist SIU investigators during interviews, discussions and negotiations with providers, suppliers, and pharmacies.</p><ul><li>
Perform retrospective and prepayment reviews of medical records to identify potential fraud, waste, and abuse and inappropriate billing practices.</li><li>
Investigate, analyze, and identify provider billing patterns to determine payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies.</li><li>
Prepare summary of findings and recommend next steps for providers.</li><li>
Identify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices.</li></ul><ul><li>
Collaborate with investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities.</li><li>
Performs other duties as assigned</li><li>
Complies with all policies and standards</li></ul><p><b>
Education/Experience:</b> Master&rsquo;s Degree and 2 years of relevant experience required. 2+ years clinical experience with independent license required; 2 years of fraud, waste, and abuse experience required; experience in provider education and managed care organization preferred; coding certification preferred.<br>
<br>
<b>License/Certification:</b> Behavioral health license - LMHC, LCSW, LMFT, LPC, LMHP, LIMHP</p><p>
Pay Range: $56,200.00 - $101,000.00 per year</p><p>
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.</p><p><br>
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.</p><p><br>
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act</p></div>

Clinical Investigator - Behavioral Health

Imagenet, LLC

<div><p><b>Claims Adjudication Manager</b></p>
<p><i>
U.S.-Based Operational Leader Overseeing Philippines Claims Adjudication</i></p><p></p><p><br>
Work Setup: <b>Remote</b></p>
<p>
Reports To: <b>SVP Operations</b></p>
<p>
Direct Oversight: <b>Philippines-based claims adjudication team (examiners, auditors, team leads)</b></p>
<p>
Hours: <b>Pacific Time Zone: Core overlap with Philippines business hours required; evening calls for client/offshore alignment</b></p><p></p><p><b><br>
Role Summary</b></p>
<p>
Imagenet is seeking an experienced, U.S.-based Claims Adjudication Manager to provide hands-on operational leadership for a claims adjudication account, which is delivered through our wholly owned global delivery center in the Philippines. This is a player-coach role for a seasoned claims subject-matter expert (SME) who can bridge U.S. client expectations and offshore delivery &mdash; directly strengthening quality, throughput, reporting accuracy, and client-facing credibility.</p><p></p><p><br>
The successful candidate combines deep adjudication expertise in both hospital (facility) and professional claims with proven experience leading and developing offshore claims teams. They will serve as the senior operational point of contact for the client, set the standard for adjudication accuracy, and build the coaching, audit, and documentation infrastructure needed to deliver consistent, high-quality outcomes at scale. They will not hesitate to role up their sleeves and dive into production and quality.</p><p></p><p><b><br>
Key Responsibilities</b></p>
<p><b>
Operational Leadership (Onshore Lead for Offshore Delivery)</b></p>
<ul>
<li>Provide day-to-day operational leadership for the Philippines-based adjudication team (examiners, auditors, and team leads), working across time zones to direct priorities and remove blockers.</li>
<li>Serve as the hands-on claims SME for the campaign &mdash; personally adjudicating complex or escalated claims and modeling correct handling for the team.</li>
<li>Drive accuracy, productivity, quality, and service-level goals; translate client requirements into clear, executable operating procedures.</li>
<li>Partner with the offshore manager and team leads to strengthen communication, information flow, and consistency of execution.</li>
</ul>
<p><b>Client Engagement &amp; Single Point of Contact</b></p>
<ul>
<li>Act as the senior operational single point of contact (SPOC) for the client, consolidating guidance from multiple client stakeholders into one consistent set of directives for the delivery team.</li>
<li>Lead client working sessions, escalations, and operational updates with confidence and credibility; provide clear written and verbal updates on performance, quality, and improvement actions.</li>
<li>Manage frequently changing client requirements &mdash; capturing, sequencing, and operationalizing new directives without disrupting production.</li>
</ul>
<p><b>Quality, Coaching &amp; Audit</b></p>
<ul>
<li>Own the quality program: reduce repeat errors, identify root causes, and close coaching gaps through targeted, SME-led feedback.</li>
<li>Align coaching responsibilities with subject-matter expertise; design and lead calibration sessions between examiners and auditors.</li>
<li>Assess auditor capability and set audit-throughput targets that balance thoroughness with release timelines.</li>
</ul>
<p><b>Reporting &amp; Production Validation</b></p>
<ul>
<li>Oversee validation of production reporting; partner with the business analyst and client to resolve reporting discrepancies (e.g., over- or under-counting) and establish a trusted tracking methodology.</li>
<li>Use data to identify capacity, monitor service levels, and demonstrate measurable improvement to the client.</li>
</ul>
<p><b>Documentation &amp; Knowledge Management</b></p>
<ul>
<li>Establish and maintain a centralized documentation and knowledge-management process for client directives, reducing reliance on individual knowledge.</li>
<li>Ensure source documentation is centralized and current so that AI-assisted retrieval and other enablement tools deliver reliable answers.</li>
</ul>
<p><b>Workforce &amp; Cross-Functional Collaboration</b></p>
<ul>
<li>Partner with HR and recruiting to accelerate hiring, rebuild the candidate pipeline, and stabilize staffing levels.</li>
<li>Collaborate with QA, training, workforce management, infrastructure/IT (including connectivity and latency monitoring for remote staff), and client services to support execution.</li>
<li>Coordinate with consultants, business analysts, and transition partners during onboarding and ramp activities.</li></ul><br>
<p></p>
<p><b>
Must-Have Qualifications</b></p>
<ul>
<li><b>6+ years of U.S. healthcare claims adjudication experience, with hands-on expertise in BOTH hospital/facility (UB-04) and professional (CMS-1500/HCFA) claims.</b></li>
<li><b>3+ years leading claims teams (managing 30&ndash;40+ examiners/auditors, directly or through team leads), ideally including offshore or BPO/shared-services teams.</b></li>
<li>Demonstrated ability to serve as a client-facing operational leader &mdash; running working sessions, owning escalations, and building client trust.</li>
<li>Strong command of claims workflows, medical terminology, coding concepts, benefits, and payer/provider processes.</li>
<li>Proven track record managing productivity, quality, service levels, and team performance in a metrics-driven environment.</li>
<li>Experience coaching examiners and reducing error rates through structured quality and calibration programs.</li>
<li>Excellent written and verbal communication; able to work effectively across cultures and time zones.</li>
<li>Strong analytical and problem-solving skills, including working with production and quality data.</li></ul><br>
<p></p>
<p><b>
Preferred Qualifications</b></p>
<ul>
<li>Experience overseeing or supporting Philippines-based or other offshore healthcare claims operations.</li>
<li>Experience supporting U.S. health plans, TPAs, healthcare BPOs, or shared-services operations.</li>
<li>Exposure to payment review, denials, appeals, or related claims functions.</li>
<li>Experience building documentation/SOP libraries and knowledge-management processes.</li>
<li>Exposure to process improvement, automation, or digital-transformation initiatives (including AI-assisted enablement tools).</li>
<li>Familiarity with claims platforms and reporting validation.</li></ul><br>
<p></p>
<p><b>
Key Competencies</b></p>
<ul>
<li>Hands-on claims adjudication expertise (hospital + professional)</li>
<li>Operational leadership of distributed / offshore teams</li>
<li>Client and stakeholder communication; single point of contact</li>
<li>Quality, coaching, and audit calibration</li>
<li>Analytical thinking, reporting validation, and problem-solving</li>
<li>Continuous improvement and cross-functional collaboration</li></ul><br>
<p></p>
<p><b>
Company Overview</b></p>
<p>
Imagenet is a leading provider of back-office support technology and tech-enabled outsourced services to healthcare plans nationwide. Imagenet provides claims processing services &mdash; including digital transformation, claims adjudication, and member and provider engagement services &mdash; acting as a mission-critical partner to these plans in enhancing engagement and satisfaction with their members and providers.</p><p></p><p><br>
The company currently serves over 70 health plans, processing millions of claims and the related structured and unstructured data elements within those claims annually. Imagenet has also developed an innovative workflow technology platform, JetStream&trade;, to support traceability, governance, and automation of claims operations for its clients.</p><p></p><p><br>
Imagenet is headquartered in Tampa, operates 10 regional offices throughout the U.S., and has a wholly owned global delivery center in the Philippines.</p></div>

Claims Adjudication Manager

Briljent

<div>
 <strong>
  Description
  <br/>
  <br/>
 </strong>
 We are seeking a detail-oriented
 <strong>
  Clinical Auditor Registered Nurse
 </strong>
 to support medical record reviews, billing compliance audits for the Indiana Health Coverage Programs. This role is responsible for evaluating quality of care, reviewing medical records and program policies and identifying compliance issues, preparing audit documentation and reports, and supporting appeals activities. The ideal candidate brings clinical knowledge, regulatory awareness, and strong analytical and writing skills. This is a remote position with occasional travel required within Indiana.
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 <br/>
 <strong>
  Key Responsibilities
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Review medical records and related documentation to evaluate provider compliance with Indiana Health Coverage Programs, CMS, AMA, and other applicable standards and regulations.
  </li>
  <li>
   Conduct medical record and compliance reviews independently and provide preliminary findings to the Lead Reviewer.
  </li>
  <li>
   Identify potential documentation deficiencies, and billing compliance issues.
  </li>
  <li>
   Maintain detailed workpapers documenting procedures performed, records reviewed, findings identified, and conclusions reached.
  </li>
  <li>
   Assist with audit responses and appeals as needed.
  </li>
  <li>
   Ensure all work aligns with state, federal, and national healthcare and Medicaid guidelines.
  </li>
  <li>
   Stay current on clinical guidelines, policies, regulations, and Indiana Medicaid program and policy updates.
  </li>
  <li>
   Research Indiana Medicaid rules and maintain internal repositories of bulletins, policies, and procedures.
  </li>
  <li>
   Adapt quickly to changing priorities, policies, regulatory updates, and review requirements while maintaining accuracy and meeting deadlines.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Requirements
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   RN license preferred; Indiana license or compact license accepted.
  </li>
  <li>
   Coding certification such as CCS or CPC strongly preferred.
  </li>
  <li>
   Candidate located in or near the Indianapolis area is preferred.
  </li>
  <li>
   At least 1 year of Medicaid claims review, billing compliance, or healthcare reimbursement experience.
  </li>
  <li>
   Familiarity with Indiana Medicaid policies, payer guidelines, and documentation requirements preferred.
  </li>
  <li>
   Knowledge of CPT coding guidelines and ICD-10 standards.
  </li>
  <li>
   Proficiency in Microsoft Excel, Word, and Outlook.
  </li>
  <li>
   Strong analytical, critical thinking, problem-solving, and technical writing skills.
  </li>
  <li>
   Ability to work independently and collaboratively in a fast-paced environment.
  </li>
  <li>
   Experience working with healthcare providers strongly preferred.
  </li>
  <li>
   Knowledge of healthcare claims data and fraud, waste, and abuse preferred.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Physical Requirements &amp; Environmental Conditions:
 </strong>
 An employee must meet these physical demands to successfully perform the essential functions of this job. Employee is regularly required to talk or hear, sit, and utilize technology tools such as a laptop computer for extended periods of time. Specific vision abilities include close vision and the ability to adjust focus. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
 <br/>
 <br/>
 <em>
  Briljent is a solutions-based company. Solutions come from creative ideas; ideas come from being creative with differences. Briljent believes diversity and inclusion are critical to the success of the company. Employment at Briljent is based on merit and professional qualifications. We do not discriminate against any employee or applicant because of race, creed, color, religion, gender, sexual orientation, national origin, disability, age, veteran status, marital status or any other basis protected by federal, state or local law, regulation or ordinance.
 </em>
</div>


Clinical Auditor - RN

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