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 Coding & Compliance Auditor performs complex operational and financial audits of provider claims using established work processes and job aides. The Auditor also mentors less experienced staff. Extensive knowledge of claim processing and BMCHP policies is required. This position also requires a working knowledge of medical terminology and coding skills to evaluate accuracy of charges according to BMCHP reimbursement policies, and industry standard billing and coding guidelines as adopted by BMCHP.

Our Investment in You:

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

Key Functions/Responsibilities:

• Demonstrates expert knowledge and understanding of BMCHP benefits, policies/procedures, provider network development and contract issues, processing system issues, Massachusetts Medicaid regulations as well as industry standards for claim adjudication.
• Performs operational and financial audits of provider claims to identify issues with system configuration, provider contracts, claims operations, provider billing accuracy, and other party liability processes.
• Adjudicates claims following established recovery guidelines and job aides.
• Identifies potential recovery projects and reports findings to management.
• Remains current with BMCHP claims adjudication processes and internal and external software systems, including Facets, CAD, and Ingenix/Code Manager.
• Achieves department production, quality requirements and individual financial recovery goals.
• Ensures multiple audit projects are completed within designated audit deadlines.
• 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 received weekly.

Qualifications:

Education:

• Bachelor’s Degree in Healthcare Administration, business related field or an equivalent.
• Combination of education, training and experience is required.
• Intermediate knowledge of medical terminology, CPT, ICD9, HCPCS coding

Preferred/Desirable:

• CPC or CCS certification a plus.

Experience:

• 2 or more years experience in a progressive role within healthcare or managed care field required.
• 3 or more years experience as a claims analyst required.

Preferred/Desirable:

• Working knowledge of Facets claim processing system preferred.
• Prior Auditing and/or Medical Record review experience desired.

Certification or Conditions of Employment:

• Pre-employment background check

Competencies, Skills, and Attributes:

• Strong oral and written communication skills; ability to interact within all levels of the department.
• A strong working knowledge of Microsoft Office products.
• Detail oriented, excellent proof reading and editing skills.
• Sensitive provider customer service skills.
• Must be able to multi-task, prioritize projects and work well with deadlines.
• Must be able to be flexible and willing to perform all necessary and appropriate duties to ensure the attainment of departmental and organizational goals.

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 440,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago, 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.