Remote Clinical Auditor I - Medical Claims & Compliance

WellSense Health Plan; United States; Remote; USD 64,000 - 93,000; Full time

Benefits offered by this job

Full-time remote work

Competitive salaries

Excellent benefits

Job summary

WellSense Health Plan is seeking a Clinical Auditor I to perform detailed retrospective chart audits, verifying that medical documentation supports paid charges. This role acts as a liaison between WellSense and external providers, collaborating with management, physicians, and clinical staff to ensure accurate billing and compliance with policy.

You will review outpatient, professional, and ancillary claims, identify discrepancies, and document findings.

Qualifications

• Bachelor's degree in nursing or equivalent experience.
• Licensed professional: RN, LCSW, LMFT, or LMHC.
• Coding Certification preferred: CPC or CCS.
• Minimum two years' experience in case management or claims auditing; clinical experience in acute care.

Responsibilities

• Verify billed hospital, physician, and ancillary services against medical records.
• Research CPT codes to clarify coding issues as needed.
• Assess provider coding accuracy and ensure charges match claims.
• Identify billing issues and document audit findings.
• Discuss audit results with provider representatives and finalize recoveries.
• Identify trends and recommend audit projects.

Skills

CPT/ICD-10 knowledge

Attention to detail

Communication skills

MS Office

Independent work

Project management

Education

Bachelor's degree in nursing

LCSW

LMHC

Job description

WellSense Health Plan is seeking a Clinical Auditor I to perform detailed retrospective chart audits, verifying that medical documentation supports paid charges. This role acts as a liaison between WellSense and external providers, collaborating with management, physicians, and clinical staff to ensure accurate billing and compliance with policy.

You will review outpatient, professional, and ancillary claims, identify discrepancies, and document findings.