WellSense Health Plan · 1 day ago
Clinical Auditor I
United States
Contract
Remote
Entry Level
2+ years expWellSense Health Plan is a growing regional health insurance company with a 25-year history of providing health insurance that works for its members. The Clinical Auditor I is responsible for performing detailed medical record audits to ensure accurate reimbursement to providers while adhering to regulations and internal policies.
Hospital & Health Care
Responsibilities
Analyze patient records, treatment plans, and medical billing documents to ensure accuracy, completeness, and strict compliance with healthcare standards and regulations
Verify that procedures and diagnoses are accurately coded using appropriate CPT, HCPCS, and ICD-10 codes. Ensure that the coding reflects the clinical documentation accurately and complies with current guidelines
Check for consistent documentation across patient records, confirming that all entries adhere to regulatory mandates, internal policies, contract stipulations, and benefit coverages
Identify any documentation or billing discrepancies during the review process. This includes spotting errors, omissions, or inconsistencies that may affect reimbursement or patient care quality, and flagging these issues as needed
Based on audit findings, regularly update and refine clinical audit guidelines and protocols
Use statistical and analytical methods to examine clinical data
Methodically review data to identify discrepancies and irregularities that could indicate non-compliance with internal policies, contractual obligations, or regulatory mandates
Analyze data trends to determine potential areas of risk that might adversely affect patient care or disrupt the organization’s operations
Continuously monitor and document recurring patterns or anomalies in clinical data
Based on the insights gathered, provide well-founded recommendations for new audit projects
Conduct both scheduled and ad hoc audits in strict accordance with established guidelines and internal processes. This involves planning and executing audit activities to ensure every clinical record is reviewed consistently while aligning with quality assurance benchmarks
Develop comprehensive audit reports that clearly outline all findings. Reports must detail discrepancies, note any process inefficiencies, and provide precise, actionable recommendations for improvement
Play a supportive role in the amendment and appeals process. This includes coordinating with providers to resolve discrepancies and ensuring the audit conclusions are fully and fairly reviewed
Finalize all audits by ensuring that all findings are documented, follow-up actions are clearly communicated, and the entire process meets the established timelines and productivity standards for the role
Collaborate closely with clinical staff, audit coordinator, and other members of the audit team on audit findings and questions
Maintain active communication with providers by preparing precise documentation, responding promptly to emails and phone calls, and offering detailed explanations of audit results
Ensure that any audit denial rationale is clearly, concisely, and accurately communicated
Continuously monitor evolving federal and state healthcare regulations along with industry standards by engaging in regular education and policy reviews. Ensure that all clinical documentation and audit processes are consistently aligned with current regulatory requirements and best practices
Evaluate clinical and reimbursement activities to determine payment compliance under WellSense clinical and reimbursement policies
Proactively identify potential fraud and abuse by scrutinizing clinical data, documenting billing errors, and highlighting opportunities to manage benefit costs and secure savings
When discrepancies or irregularities signal deeper issues, refer cases to the Special Investigations Unit (SIU) or the Third-Party Liability team
Detect potential quality of care or utilization issues during audits and promptly report these findings to management
Assist in educating clinical personnel on documentation requirements and audit practices to enhance compliance and overall patient care quality
Qualification
Required
Bachelor's degree in nursing or an equivalent combination of education, training, and experience is required
Two years CM, UM, claims auditing or other clinical health insurance role
Two years minimum RN experience in acute care setting
Behavioral Health and/or DRG experience required
Valid Registered Nurse License required
Preferred
Coding Certification Preferred - CPC or CCS certification
Basic familiarity with CPT, ICD-10 and HCPCS coding is preferred
Claims processing experience is preferred
Benefits
Full-time remote work
Competitive salaries
Excellent benefits
Company
WellSense Health Plan
A nonprofit health plan serving Medicare, Individual & Family, and Medicaid plan members in Massachusetts & New Hampshire.
1001-5000 employees
H1B Sponsorship
WellSense Health Plan has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (1)
2024 (8)
2023 (2)
2021 (2)
2020 (1)
Funding
Current Stage
Late StageLeadership Team
Heather Thiltgen
President & CEO
Diana Cruz
Chief Operating Officer
Company data provided by crunchbase