Clinical Auditor I

WellSense Health Plan; New Hampshire; Sur place; USD 64 000 - 93 000; Plein temps

Résumé du poste

WellSense Health Plan is seeking a Clinical Auditor I to perform detailed retrospective chart audits, comparing medical documentation with charged amounts. The role functions as a liaison between WellSense and external providers, ensuring coding accuracy and compliance with policy.

The position involves collaboration with management, physicians, and clinical staff to verify paid charges and identify coding discrepancies, with opportunities to improve utilization and reimbursement practices.

Qualifications

• Bachelor’s degree in nursing or an equivalent combination of education, training, and experience is required.
• Licensed RN, LCSW, LMFT or LMHC is required.
• Coding Certification CPC or CCS preferred.

Responsabilités

• Utilizes CPT, ICD-10, and HCPCS codes to verify billed services against medical records.
• Research CPT codes to clarify coding issues.
• Assess provider coding for accuracy and confirm charges match claims.
• Review outpatient, professional, and ancillary claims for billing and payment accuracy.
• Determine payment compliance per WellSense policies.
• Identify documentation and billing issues during reviews.
• Refer cases for SIU or Third-Party Liability investigations when appropriate.
• Document audit findings and discuss with provider representatives.

Connaissances

Communication skills

Detail oriented

Analytical thinking

Project management

Formation

Bachelor’s degree in nursing or equivalent

Licensed Clinician (LCSW/LMFT/LMHC)

Coding Certification (CPC/CCS) preferred

Outils

Microsoft Office

Description du poste

WellSense Health Plan is a nonprofit health insurance company serving more than 680,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded more than 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances.

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 Clinical Auditor I performs detailed, retrospective chart audit review, comparing medical documentation with paid charges. The Clinical Auditor I is a liaison and resource between WellSense Health Plan and external providers, working collaboratively with a diverse group, including management, physicians, clinical and non-clinical personnel. While verifying billed charges on paid claims, the auditor utilizes the WellSense policies and industry standard coding rules.

Our Investment in You:

Key Functions/Responsibilities:

• Utilizes basic knowledge of CPT, ICD-10, and HCPCS codes to verify billed hospital, physician and ancillary services against medical record documentation.
• Research CPT codes to clarify coding issues, as required
• Assesses provider coding for accuracy and confirms charges match the provider’s claim based on clinical documentation.
• Outpatient, professional, ancillary claim reviews ensure billing and payment accuracy in alignment to medical records, policy adherence, contract adherence, and benefit coverage
• Determines payment compliance per WellSense clinical and reimbursement policies.
• Identifies documentation and billing issues during the review process.
• Identify possible fraud and abuse, document billing errors, and benefit cost management and savings opportunities.Refer cases to the SIU or Third-Party Liability team when appropriate for further investigation.
• Documents audit findings and meet with provider representatives to discuss.
• Responds to amendment documentation and finalizes all audits, processing recoveries of unsupported charges consistent with WellSense reimbursement methods.
• Meets position productivity level and provides a daily update.
• Identifies potential quality of care or utilization issues and reports to management.
• Communicates with providers. Prepares documentation, responds to emails and phone calls. Ensures that communicated audit denial rationale is clear, concise, and accurate.
• Identifies audit trends and makes recommendations for potential audit projects.
• Maintains an established level of claims adjustment quality.
• Updates clinical audit guidelines and protocols

Supervision Exercised:

None

Supervision Received:

Direct and Indirect supervision is received weekly.

Qualifications:

Education Required:

Bachelor's degree in nursing or an equivalent combination of education, training, and experience is required OR Licensed Clinical Social Worker, Licensed Marriage Family Therapist or Licensed Mental Health Counselor

Education Preferred:

Coding Certification preferred – CPC or CCS certification

Experience Required:

Minimum of two years of experience in case management, utilization review or claims auditing with a minimum of two years of clinical experience in an acute care setting required.

Knowledge of CPT, ICD-10, and HCPCS coding is preferred.

Prior External Auditing and/or Medical Record Review experience is preferred.

Required Licensure, Certification or Conditions of Employment:

Valid license as a Registered Nurse, Licensed Clinical Social Worker, Licensed Marriage/Family Therapist or Licensed Mental Health Counselor is required.

Successful completion of pre-employment background check

Competencies, Skills, and Attributes:

• Ability to relate and communicate positively, effectively, and professionally.
• Ability to work independently and as a member of a team.
• Detail oriented with analytical and problem-solving skills.
• Ability to successfully organize and manage projects.
• Excellent proof reading and editing skills.
• Proficient oral, written and presentation skills.
• Ability to work well under pressure and respond to changing needs and complex environments.
• Strong working knowledge of Microsoft Office products.

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.

Compensation Range

$64,000 - $93,000

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. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.

Note :

This range is based on Boston-area data, and is subject to modification based on geographic location.

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