Coding and Compliance 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:

The Coding and Compliance Auditor 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 or more years work experience in the healthcare industry including at least 3 years of work related to medical billing and coding

Experience Preferred/Desirable:

* Claim audit experience

* 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