Medical Claims Review, Auditor

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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:

The Medical Claims Auditor manages the process by which claims failing established clinical-related adjudication parameters are evaluated for payment.  Leveraging clinical and/or coding expertise in the performance of the key functions of the position. The MCA considers a variety of factors including, but not limited to, Plan benefit, reimbursement and medical policies, provider contracts, correct coding guidelines, and adequacy of documentation of the service in question, whether the activity is the analysis of claims having failed the adjudication process for clinical/coding-related reasons or is the verification that services billed and paid were documented as having been provided.

Our Investment in You:

• Full-time remote work
• Competitive salaries
• Excellent benefits

Key Functions/Responsibilities:

• Analyzes claims that have failed established clinical -related adjudication parameters by applying knowledge of CPT, HCPCS and ICD 10.
• Establishes root cause of claims failure and applies Plan benefit, reimbursement and/or medical policies, contract terms, etc. to determine the appropriate resolution.
• Prioritizes claims/cases based on urgency
• Consults staff in the Office of Affairs (OCA), Business Integration, Claims, Legal, claims, Benefits, Payment Policy,  and other departments, as necessary, to resolve atypical issues.
• Acts as internal consultant to various internal departments, such as Customer Care and Provider Relations, regarding clinical/coding-related adjudication parameters and their application in specific cases
• Applies, during the assigned clinical audits, knowledge of CPT, HCPCS, ICD10, provider contract terms, and Plan clinical and reimbursement policies to the validation of services in the medical record, and the accuracy of payment.
• Documents clinical audit findings and communicates them to provider’s; records final audit findings and, where appropriate, processes recoveries or payments.
• Identifies, during the analysis of failed claims or clinical audits, potential deficiencies in the delivery of care and refers to the appropriate department.
• Identifies opportunities to improve or streamline clinical/coding-related adjudication parameters and/or their effect on claims processing and escalates to management for review and communication.
• Maintains established productivity and quality metrics.
• Other duties as assigned

Supervision Exercised: 

·       Provides technical assistance to less experienced staff members

Supervision Received: 

·       Indirect supervision is received weekly

Qualifications:

Education:

•  Bachelor's degree in Nursing with certification in coding either through AAPC or AHIMA or the equivalent combination of Coding Certification through AAPC or AHIMA, education, training and experience

Experience:

·       If a Registered Nurse:

o   Minimum one year medical claim auditing or medical record review and Coding certification in AAPC or Ahima

o   Minimum two years RN experience in a clinical setting

·       If a Certified Coder:

o   Minimum seven years direct coding experience

Required:  Licensure, Certification or Conditions of Employment: 

·       Successful completion of pre-employment background check

·       Coding Certification through AAPC of AHIMA, experience with Behavioral Health coding a plus

Competencies, Skills, and Attributes: 

• Proficiency in the use of Facets claim processing system
• Strong oral and written communication skills.
• A strong working knowledge of Microsoft Office and Excel products.
• Demonstrated ability to successfully organize and manage projects.
• Ability to interact within all levels of the organization and external contacts.
• Must be team and detail oriented with strong analytical and problem solving skills and able to work in a fast-paced environment.
• Works independently without the need to assign tasks/self-motivated
• Proven ability to maintain confidentiality.

Working Conditions and Physical Effort: 

• Regular and reliable attendance is an essential function of the position.
• Very limited physical effort required. Occasional bending and lifting up to 30 lbs.
• No or very limited exposure to physical risk.
• Ability to work 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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