WellSense Health Plan · 11 hours ago
Coding and Compliance Auditor-Behavioral Health
United States
Full-time
Remote
Senior Level
5+ 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 Coding and Compliance Auditor-Behavioral Health is responsible for performing complex reviews and adjustments of medical claims to ensure accuracy in claim payments, utilizing data analysis to align with payment policies and regulatory requirements.
Hospital & Health Care
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
Qualification
Required
Bachelor's Degree or equivalent combination of education, training and related experience required
5 + years of work experience in Behavioral Health claims processing and/or health insurance experience working at a Behavioral Health facility or practice
At least 3 years of work related to medical billing and coding
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
Successful completion of pre-employment background check
Preferred
Claim audit experience, (Behavioral Health Claims experience desirable)
Prior Medicaid/Medicare exposure
Working knowledge of Facets
SQL training
CPC or CCS certification 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
Funding
Current Stage
Late StageLeadership Team
Heather Thiltgen
President & CEO
Diana Cruz
Chief Operating Officer
Company data provided by crunchbase