Claims Adjudicator

WellSense Health Plan is a nonprofit health insurance company serving members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances.

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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:

Responsible for the accurate and timely processing of claims.  Must meet published quality and productivity standards.  Also, responsible for simple adjustments to previously processed claims. 

 

Our Investment in You:

·       Full-time remote work

·       Competitive salaries

·       Excellent benefits

 

Key Functions/Responsibilities:

  • Evaluates and processes claims in accordance with company policies and procedures according to productivity and quality standards.
  • Interprets and processes routine and less complex claims including CMS 1500 and UB04.
  • Reviews and analyzes data from system-generated reports for in-process claims in order to identify and resolve errors prior to final adjudication.
  • Alerts claims management to claims aging issues as well as provider billing problems.
  • Maintains current knowledge of company members' benefits, policies/procedures, provider network development and contract issues, processing system issues, Massachusetts Medicaid regulations, as well as industry standards for claims adjudication.
  • Consistently maintains production standards based on transactions/units per hour
  • Consistently meets quality standards 

 

Qualifications: 

Education:

  • High School degree or equivalent required.
  • Associate degree or some college coursework preferred.

 

Experience:

  • Two years or more years experience in managed care claims processing preferred.

 

Competencies, Skills, and Attributes:

  • Working knowledge of medical terminology as well as CPT4, HCPCS and ICD9 coding sets and HIPAA regulations.
  • Knowledge of Microsoft Office and FACETS preferred.
  • Ability to maintain production level and quality goals.
  • Follow through on commitments and meets deadlines
  • Work is thorough, accurate, and effective.
  • Demonstrates ability to complete assigned work in a timely fashion.

 

Working Conditions and Physical Effort:

  • Ability to work OT during peak periods.

 

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

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