CPC or CCS certification and/or SQL training; proficiency with Facets and Microsoft Office (preferred)
Requirements:
Performs operational and financial audits of provider claims to identify overpayments and inform resolution of root cause issues with system configuration, provider contracts, claims operations, provider billing accuracy, and other party liability processes
Adjusts claim payments and adjudicates claims following established recovery guidelines and job aides
Identifies potential recovery projects and reports findings to management
Mentors and coaches less experienced staff and new hires
Job description
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 Coding and Compliance Auditor- Behavioral Health performs complex review and adjustments of medical claims to ensure accuracy in claim payments. This is accomplished through data analysis to ensure alignment with payment policies, medical policies, correct coding, and state and federal regulatory requirements.
Our Investment In You
Full-time remote work
Competitive salaries
Excellent benefits
Key Functions/Responsibilities
Performs operational and financial audits of provider claims to identify overpayments and inform resolution of root cause issues with system configuration, provider contracts, claims operations, provider billing accuracy, and other party liability processes
Adjusts claim payments and adjudicates claims following established recovery guidelines and job aides
Identifies potential recovery projects and reports findings to management
Achieves department production, quality requirements, and individual financial recovery goals
Participates in special projects and initiatives
Assists in developing/revising departmental policies and procedures
Attends and participates in team meetings
Mentors and coaches less experienced staff and new hires
Supervision Exercised
None
Supervision Received
Direct supervision is received weekly
Qualifications
Education Required:
Bachelor’s Degree or equivalent combination of education, training and related experience required.
Experience Required
5 + years of work experience in Behavioral Health claims processing and/or health insurance experience working at a Behavioral Health facility or practice. This also includes at least 3 years of work related to medical billing and coding
Experience Preferred/Desirable
Claim audit experience, (Behavioral Health Claims experience desirable)
Prior Medicaid/Medicare exposure
Working knowledge of Facets
SQL training
Required Licensure, Certification Or Conditions Of Employment
CPC or CCS certification preferred
Successful completion of pre-employment background check
Competencies, Skills, And Attributes
Intermediate to expert knowledge of medical terminology, CPT, ICD9, HCPCS coding is required
Ability to work within large datasets to identify errors, anomalies, and outliers
Works with a high level of accuracy, attention to detail, and with superb work quality
Strong oral and written communication skills; ability to interact effectively with both internal WellSense colleagues as well as with external constituents such as providers and suppliers
Intermediate Excel experience required as well as proficiency using other Microsoft Office products including Word, Outlook, and PowerPoint
Must be able to multi-task, prioritize projects and work well with deadlines
Working Conditions And Physical Effort
Regular and reliable attendance is an essential function of the position
Work is performed in a remote, work from home environment
Ability to work at a computer for entire work shift
No or very limited physical effort required. No or very limited exposure to physical risk
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
