This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description As a Reimbursement Professional, you will be a pivotal expert, optimizing financial outcomes through accurate, timely, and compliant claim processing. - Manage and analyze complex reimbursement methodologies, payer contracts, and regulatory requirements to maximize revenue and minimize denials. - Identify trends, appeal claims, and collaborate with departments and payers to resolve discrepancies. - Implement efficient billing practices. - Demonstrate a solid understanding of healthcare accounts receivable. - Work knowledge of Payor Rules & Regulations, understanding contract language, CCI Coding Issues, and read and interpret DOFR. - Determine correct systems to locate pertinent information, which may include IDX, MPV, Medical Records Systems, Insurance Payor Websites, and Code Correct Website. - Demonstrate strong analytical skills in daily duties. - Communicate effectively with peers as well as internal and external customers. - Manage multiple expectations, tasks, and deadlines effectively. - Timely review of electronic communication to stay informed of changes that affect your position. Qualifications - High School Diploma or GED. - Five years experience working in healthcare revenue cycle and/or a professional medical billing office. - One year experience with IDX Practice Management System required. - Knowledge of physician billing regulations. - Understanding of professional claims and billing procedures. - Strong MS Excel skills to interpret and analyze high volume of data. - Strong analytical skills to identify key issues from large amounts of detailed data. - Ability to build and maintain working relationships with all levels of staff, physicians, and other contacts. Requirements - Six years experience working in healthcare revenue cycle, in a professional medical billing office as well as experience in reviewing and interpreting contracts. - One year experience with IDX Practice Management System.

• Analyze financial data including revenue streams, cost structures, margins, and unit economics. • Support budgeting, forecasting, and financial planning processes. • Build and maintain financial dashboards and management reports using BI tools (Looker Studio, Tableau, Power BI). • Develop financial models for revenue forecasting, scenario analysis, and profitability evaluation. • Work with transaction-heavy datasets related to payments, crypto flows, mining rewards, digital assets, and platform fees. • Monitor product and financial performance metrics ARPU, LTV, CAC, churn, contribution margin. • Support P&L analysis across products and regions. • Automate recurring financial reports and reporting pipelines. • Ensure data consistency between finance, product, and operational systems. • Prepare structured presentations and analytical summaries for CFO and executive team.

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 Business Encounter Data Analyst is responsible for compiling and analyzing encounter data and understanding the claim impact of changes and decision to the business process to ensure that CMS and State Service Level Agreements (SLAs) are achieved. This individual will support the encounter data lifecycle process working closely with business and technical resources as well as document and illustrate business requirements, processes, and deficiencies across the organization, our vendors, and our regulators. Our Investment in You: · Full-time remote work · Competitive salaries · Excellent benefits Key Functions/Responsibilities: · Understand the claims encounter data requirements in detail to ensure claims data is complete, accurate, and timely. · Responsible for reviewing encounter rejections and providing resolution of minor to complex data/system issues or processes. · Responsible for the development and maintenance of supporting business processes and workflows. · Recognize inconsistencies and gaps to improve productivity, accuracy and data usability and streamlining procedures and policies. · Provide critical analysis of functional performance, and make recommendations for enhancements, and process improvements. · Build, sustain and leverage relationships to constantly allow for continuous improvement of the encounter data business process. · Provide encounter data support to vendors and ensure understanding of regulatory encounter requirements. · Participate in claims encounter initiatives such as working with IT and others internal departments to automate claims encounters functions. · Understanding of how claims payment methodologies, adjudication processing and CMS and State encounter regulations interrelate to maintain compliant encounter reconciliation processes and SLA’s. · Stay current with the needs and operations of the regulatory deliverables. · Interacts with business stakeholders, internal and external as appropriate, to understand new business requirements and enhancement requests. · Provide business encounter subject matter expertise for internal departments and both CMS and State agencies. · Performance for timely and accurate reviews must meet or exceed internal, CMS, and State SLA requirements. · Other duties as assigned Supervision Exercised: · None Supervision Received: · Indirect supervision is received weekly Qualifications: Education Required: · Bachelor's Degree in a related field or the equivalent combination of training and experience. Education Preferred: · AHIMA or other nationally recognized Coding/Billing Certification. Experience Required: · 5 or more years experience in a fast paced, managed healthcare environment. · 5 or more years experience with encounter data operations, claims processing, and/or provider billing. · 3 or more years of claim coding and billing processes, including CPT, ICD-10 and HCPCS coding. · Advanced knowledge of HIPAA regulations and 837 EDI standards. · Experience working with Medicaid, Medicare or commercial encounter, coding and/or regulatory guidelines. Experience Preferred/Desirable: · Edifecs encounter data software. · Cognizant Facets claim adjudication system. · Experience with industry standard payment rules and methods. Required Licensure, Certification or Conditions of Employment: · Successful completion of pre-employment background check Competencies, Skills, and Attributes: · Effective collaborative and proven process improvement skills. · Good communication skills, both oral and written, ability to interact well with others at all levels, strong organizational skills, strong customer service skills and orientation. · A strong working knowledge of Microsoft Office products. · Independent thinker and problem solver with an analytical mind and the ability to solve complex data and workflow issues. · Detail oriented. 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

Northeast Family Services is looking for a professional Excel guru with exceptional administrative, reporting, and data analytics skills to join our growing team as Clinical Data and Quality Coordinator. As an important member of the operations and quality assurance team, the Clinical Data and Quality Coordinator, in partnership with the QA Manager, will be the in-house expert for all EHR (Electronic Health Record) related projects. Managing and tracking daily productivity reports is a key function of this role, as well as establishing KPIs, QA Plans, data utilization, monitoring, and reporting on compliance. If you're looking to make a change and put your administrative, reporting, and data analytics skills to use, don’t miss this opportunity to take your career to the next level and join a growing, well-regarded organization that truly cares for their employees and clients! This is a remote position, but must reside in RI, MA, NH, or NY. Responsibilities: - Collaborate with QA Manager to review, quality check, and clean data sets - Provide a high level of attention to detail and consultative service skills with interactions of staff - Participate in development of training plans for data utilization - Acts as project coordinator for all Clinical Quality related projects such as establishing KPIs, Quality Assurance Plans, monitoring, and reporting on compliance - Responsibility for problem solving, assessing processes and issues, and collaborating with staff and providers to develop solutions resulting in efficient and functional workflows for end users of our software application. - Identifies, assesses, troubleshoots EHR related issues as they occur, and sees through to full resolution. - Coordinate documentation and training. - Maintains proper user control by adding and deactivating users and updating credentials as necessary - Maintains confidentiality of all patient/client and employee information - Collaborates with Program Directors to disseminate and review data as required - Participates in agency meetings and in-services. Completes staff training as required - Other duties as assigned Qualifications: - High School Diploma or equivalent - Minimum 2 years of experience with data analytics - Minimum 2 years of (EHR) Electronic Health Records technical support, training, and administration experience preferred - Experience in supporting behavioral health programming - Extensive knowledge of and experience with various computer programs including Word, Excel, and Outlook. - SQL experience is a plus! - Excellent communication skills - Ability to formulate positive collaborative relationships with the program managers and staff - Ability to work remotely and must reside in RI, MA, NH, or NY. Benefits: - Health, Dental & Vision - 3 weeks paid vacation - 11 Paid holidays (including Juneteenth, the day after Thanksgiving, Christmas Eve, and NY Eve.) - Generous sick time including mental health days - 401k retirement plan with up to 4% match - Voluntary short and long-term disability - Voluntary Life Insurance - Dependent care savings account - Mileage reimbursement - Longevity award - Monetary bonus and a vacation day annually - Company provided laptop and cell phone - Opportunity for professional growth - Supervision for licensure provided - Tuition Reimbursement - Personal cell phone discount Hours / Compensation: - Full Time - Salary $50,000 - $60,000