Clinical Auditor

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:

This position can be filled as either a Clinical Auditor I or a Clinical Auditor II:

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.

The Clinical Auditor II performs detailed medical record and chart audit review of the health plan's inpatient, outpatient, professional and ancillary claims to ensure that all reimbursement to the provider is paid accurately. The Clinical Auditor II is a liaison and resource between the health plan and external providers, working collaboratively with a diverse group, including management, physicians, clinical and non-clinical personnel.

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
• Inpatient 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.
• Trains staff on audit protocols and processes. Mentors less experienced staff and new hires.
• Updates clinical audit guidelines and protocols
• Develops new clinical audit guidelines and protocols

Supervision Exercised:

• None

Supervision Received:

• Direct supervision is received weekly.

Qualifications:

Education:

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

Experience:

• 2 years minimum clinical claim/medical record auditing
• 2 years minimum RN experience in acute care setting

Certification or Conditions of Employment:

• Coding Certification Required - CPC or CCS certification required to be considered for Clinical Auditor II
• Valid Registered Nurse License required
• Pre-employment background check

Competencies, Skills, and Attributes:

• Knowledge of health insurance industry trends and technology
• 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.
• Strong 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.
• Ability to interact within all levels of the organization as well as with external contacts
• Demonstrated ability to successfully plan, organize and manage projects.
• Demonstrated ability to compile, format, analyze, and present data to a variety of individuals, including hospital representatives, physicians, and management.

Working Conditions and Physical Effort:

• Regular and reliable attendance is an essential function of the position.
• Work is normally performed in a typical interior/office work environment.
• 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