Clinical Auditor I: Coding & Claims Integrity

WellSense Health Plan; New Hampshire; On-site; USD 64,000 - 93,000; Full time

Job summary

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.

Responsibilities

• 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.

Skills

Communication skills

Detail oriented

Analytical thinking

Project management

Education

Bachelor’s degree in nursing or equivalent

Licensed Clinician (LCSW/LMFT/LMHC)

Coding Certification (CPC/CCS) preferred

Tools

Microsoft Office

Job description

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.