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.

The Clinical Auditor I performs detailed medical record audit review of the health plan’s outpatient, professional and ancillary claims to ensure that all reimbursement to the provider is paid accurately.

Our Investment in You:

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

Key Functions/Responsibilities:

• Knowledge of CPT, ICD-10, and HCPCS codes to verify billed hospital, physician and ancillary services against medical record documentation
• Researches CPT codes to clarify coding issues, as required
• Assesses provider coding for accuracy and confirms charges are accurate based on clinical documentation
• Outpatient, professional, ancillary claim reviews ensure billing and payment accuracy in alignment to medical records, policy adherence, contract adherence, and benefit coverage
• Determines payment compliance per WellSense clinical and reimbursement policies
• Identifies documentation and billing issues during the review process
• Identify possible fraud and abuse, document billing errors, and benefit cost management and savings opportunities
• Refer cases to the SIU or Third Party Liability team when appropriate for further investigation
• Documents Audit Findings
• Supports amendment/appeals process and finalizes all audits
• Meets position productivity level
• Identifies potential quality of care or utilization issues and reports to management
• Communicates with providers
• Prepares documentation, responds to emails and phone calls
• Ensures that communicated audit denial rationale is clear, concise, and accurate
• Identifies audit trends and makes recommendations for potential audit projects
• Updates clinical audit guidelines and protocols

Qualifications:

Education:

• Bachelor’s degree in Nursing or an equivalent combination of education, training, and experience is required

Experience:

• 2 years CM, UM, claims auditing or other clinical health insurance role
• 2 years minimum RN experience in acute care setting

Certification or Conditions of Employment:

• Coding Certification Preferred - CPC or CCS certification
• Valid Registered Nurse License required
• Valid Motor Vehicle Operator’s license and dependable transportation required
• Pre-employment background check

Competencies, Skills, and Attributes:

• Clinical terminology
• Ability to relate and communicate positively, effectively, and professionally
• Ability to work independently and as a member of a team
• Detail oriented with analytical and problem solving skills
• Ability to successfully organize and manage projects
• Excellent proof reading and editing skills
• Proficient oral, written and presentation skills
• Ability to work well under pressure and respond to changing needs and complex environments
• Strong working knowledge of Microsoft Office products

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 will require proof of COVID-19 vaccination(s) as a term of employment for all employees. The company may make exceptions to this requirement in certain limited circumstances for religious or medical purposes.