[Hiring] Medical Claims Auditor @WellSense Health Plan

Role Description

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.

• 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, 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 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 during assigned clinical audits.
• Documents clinical audit findings and communicates them to providers; records final audit findings and, where appropriate, processes recoveries or payments.
• Identifies potential deficiencies in the delivery of care during the analysis of failed claims or clinical audits 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.

Qualifications

• 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.
• If a Registered Nurse:
  • Minimum one year medical claim auditing or medical record review and Coding certification in AAPC or AHIMA.
  • Minimum two years RN experience in a clinical setting.
• If a Certified Coder:
  • Minimum seven years direct coding experience.
• Preferred/Desirable: Two years’ experience in health care insurance, or provider coding or claims processing settings.

Requirements

• Successful completion of pre-employment background check.
• Valid MA or NH Registered Nurse license or eligible OR valid AAPC or AHIMA coding certification.
• Valid MA or NH Motor Vehicle Operator’s license and dependable transportation.

Benefits

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

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.
• Ability to travel to providers, as assigned.
• Ability to work during peak periods.
• No or very limited physical effort required. No or very limited exposure to physical risk.
• Occasional bending and lifting up to 30 lbs. may be required.

Compensation Range

$57,500 - $83,500. This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer.