Claims Quality Inspector

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 Claims Quality Inspector is responsible for the thorough and accurate review of adjudicated claims and Enrollment entry against established corporate guidelines and protocols specific to claim adjudication and Enrollment entry. Ideal candidates will maintain a broad knowledge of corporate claims processing and enrollment entry rules for use in conducting all review functions. 

Our Investment in You:

·       Full-time remote work

·       Competitive salaries

·       Excellent benefits

Key Functions/Responsibilities:

• Conduct accurate and timely quality reviews of claim adjudication activities including appropriate adjudication decisions, accuracy of claim payment in compliance with adjudication policies and procedures, job aids and guidelines
• Perform quality audits on Membership eligibility and enrollment entry for accuracy and timeliness in accordance with regulatory standards and regulatory agencies
• Document all findings in QC tracking system and provide clear communication and documentation for any error determinations
• Consistently meet quality, productivity and timeliness standards set by management
• Collaborate with other team members to meet team goals
• Update and maintain reference materials and QA resource documents to ensure consistent findings and determinations
•  Support internal department audits by demonstrating process workflow and providing system documentation and samples as requested by auditor or management
• Provide immediate notification to management as urgent issues or incorrect processing trends are identified
• Assist in the rebuttal process by providing supporting documentation and reference tools sited in the determination
• Provide suggestions on new process documentation and materials to support quality initiatives and to improve overall performance and compliance across the Operations teams
• Identify and document defects, inconsistences and potential risk in workflow process and documentation.
• Maintain a comprehensive understanding of appropriate departmental policies and procedures and audit specifications
• Effectively manage time and inventory within departmental guidelines
•  May be assigned to work on special projects and business initiatives by management

Supervision Exercised:

·       None

Supervision Received:

·       Direct supervision is received daily.

Qualifications:

Education Required:

• High School Diploma or GED required

Education Preferred

• Bachelor’s degree and/Claims adjudication or medical billing/coding certification preferred

Experience Required:

·       At least 2 years of experience in a Claims or QC/Inspector role within the managed care industry, or

·       At least 5 years of experience processing medical claims

Experience Preferred/Desirable:

• Prior experience within the Medicare, Medicaid, or other regulated Managed Care payer environment
• Prior experience with coordination of benefits or subrogation
• Familiarity with Facets claims administration platform
• Prior Enrollment quality auditing experience

Required Licensure, Certification or Conditions of Employment:

• Pre-employment background check

Competencies, Skills, and Attributes:

• Deep and demonstrated knowledge of medical claims processing
• Very strong attention to detail required
• Ability to learn quickly and stay up-to-date as claims policies and procedures evolve over time
• Demonstrated competency with MS Office and MS Windows
• Excellent analytical and written communication skills
• Excellent organizational skills
• Must be able to prioritize projects and work well with deadlines

• Must be flexible and willing to perform all necessary and appropriate duties to ensure the attainment of departmental and organizational goals
• Ability to maintain a high level of confidentiality

• Requires the ability to balance multiple priorities and function in a complex, rapidly changing environment

Working Conditions and Physical Effort:

• Regular and reliable attendance is an essential function of the position.
• Ability to work OT during peak periods.
• Ability to work East Coast business hours (9am – 5pm Monday-Friday)

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