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 Claims Quality Inspector is responsible for the thorough and accurate review of adjudicated claims and Enrollment entry against established corporate guidelines and protocols specific to claim adjudication and Enrollment entry. Ideal candidates will maintain a broad knowledge of corporate claims processing and enrollment entry rules for use in conducting all review functions. Our Investment in You: · Full-time remote work · Competitive salaries · Excellent benefits Key Functions/Responsibilities: · Conduct accurate and timely quality reviews of claim adjudication activities including appropriate adjudication decisions, accuracy of claim payment in compliance with adjudication policies and procedures, job aids and guidelines · Perform quality audits on Membership eligibility and enrollment entry for accuracy and timeliness in accordance with regulatory standards and regulatory agencies · Document all findings in QC tracking system and provide clear communication and documentation for any error determinations · Consistently meet quality, productivity and timeliness standards set by management · Collaborate with other team members to meet team goals · Update and maintain reference materials and QA resource documents to ensure consistent findings and determinations · Support internal department audits by demonstrating process workflow and providing system documentation and samples as requested by auditor or management · Provide immediate notification to management as urgent issues or incorrect processing trends are identified · Assist in the rebuttal process by providing supporting documentation and reference tools sited in the determination · Provide suggestions on new process documentation and materials to support quality initiatives and to improve overall performance and compliance across the Operations teams · Identify and document defects, inconsistences and potential risk in workflow process and documentation. · Maintain a comprehensive understanding of appropriate departmental policies and procedures and audit specifications · Effectively manage time and inventory within departmental guidelines · May be assigned to work on special projects and business initiatives by management Supervision Exercised: · None Supervision Received: · Direct supervision is received daily. Qualifications: Education Required: · High School Diploma or GED required Education Preferred · Bachelor’s degree and/Claims adjudication or medical billing/coding certification preferred Experience Required: · At least 2 years of experience in a Claims or QC/Inspector role within the managed care industry, or · At least 5 years of experience processing medical claims Experience Preferred/Desirable: · Prior experience within the Medicare, Medicaid, or other regulated Managed Care payer environment · Prior experience with coordination of benefits or subrogation · Familiarity with Facets claims administration platform · Prior Enrollment quality auditing experience Required Licensure, Certification or Conditions of Employment: · Pre-employment background check Competencies, Skills, and Attributes: · Deep and demonstrated knowledge of medical claims processing · Very strong attention to detail required · Ability to learn quickly and stay up-to-date as claims policies and procedures evolve over time · Demonstrated competency with MS Office and MS Windows · Excellent analytical and written communication skills · Excellent organizational skills · Must be able to prioritize projects and work well with deadlines · Must be flexible and willing to perform all necessary and appropriate duties to ensure the attainment of departmental and organizational goals · Ability to maintain a high level of confidentiality · Requires the ability to balance multiple priorities and function in a complex, rapidly changing environment Working Conditions and Physical Effort: · Regular and reliable attendance is an essential function of the position. · Ability to work OT during peak periods. · Ability to work East Coast business hours (9am – 5pm Monday-Friday) Compensation Range $20.19 - $28.13 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

Charles Taylor is a highly successful global provider of professional services to the insurance industry. We are seeking a seasoned workers’ compensation adjuster to join our Third-Party Administration team. This is a remote role, open to candidates who live in California. Job Summary The Workers Compensation Claims Adjuster is responsible for managing all aspects of a workers compensation claim which includes determining compensability, verifying coverage, administering disability and medical benefits, skillfully negotiating claim resolutions, troubleshooting and assisting injured employees, employers and medical/legal professionals with any service needs throughout the lifespan of a claim. Essential Functions - Receives newly reported claims - Maintains and updates claim notes throughout lifespan of claim - Records claim information in electronic database - Interviews claimants, insureds, medical professionals and witnesses to determine claim validity - Communicates claim compensability decisions to claimant, employer and medical provider - Sets appropriate reserves based on nature/extent of injury - Calculates lost time wages, makes disability payments directly to claimants and diaries future payments as appropriate - Orders independent medical examination as necessary and prepares all relevant documentation for physician review - Maintains regular correspondence with claimants, insureds, and nurse case manager to include claim updates, medical appointments, or issues with disability payments - Reviews and processes medical bills through third-party vendor for additional discount opportunities - Aggressively collaborates with claimants and insureds to ensure early return-to-work is pursued - Works in partnership with legal counsel to warrant that insured’s interests are protected on litigated claims which includes providing all relevant claim documentation needed for defense counsel to successfully defend claim and evaluate ultimate claim exposure - Attends settlement conferences, mediations, and hearings on behalf of the insurance company/insured - Reviews and approves defense attorney bills within authority - Works with underwriting to help provide relevant information on losses for renewal rates as well as Risk Management to identify trends and may interact with agents for insureds on losses - Responds to State requests for health cost disputes, applications for hearings and penalty assessment letters - Identifies subrogation potential and pursues recovery - Leads claim reviews with clients as requested - Other duties as assigned Requirements - 10 years of experience adjusting Workers Compensation Claims in California required - SIP Certification required - Bilingual (Spanish/English) required - Must be current with CEU's - Proficiency in entire Microsoft Office suite - Knowledge of relevant workers compensation laws - Strong grasp of medical terminology - Familiarity with medical cases and how treatment typically progresses - Excellent oral and written communication abilities - Attention to detail and good organization skills - Ability to negotiate issues and settlements - Strong focus on customer service which includes timely response to requests/inquiries - Ability to adapt to changing technologies and learn functionality of new equipment and systems - Ability to establish and maintain effective working relationships with others Charles Taylor offers a competitive salary commensurate with experience and excellent benefits including medical, dental, vision, life insurance and 401(K) with match. If you are seeking a career where you can achieve great things for great clients in a supportive and collaborative environment, then we may be the place for you. Values At Charles Taylor, our values define our identity, principles and conduct. This person will demonstrate and champion Charles Taylor Values by ensuring Agility, Integrity, Care, Accountability and Collaboration. Equal Opportunity Employer Here at Charles Taylor, we are proud to be an Inclusive Employer. We provide an environment of mutual respect with zero tolerance to discrimination of any kind regardless of age, disability, gender identity, marital/ family status, race, religion, sex, or sexual orientation. Our external partnerships and the dedicated work we do in promoting a transparent and fair recruitment and selection process all contribute to the successful, inclusive, and diverse culture and environment which we are proud to be a part of at Charles Taylor. About Charles Taylor Charles Taylor is an independent, global provider of claims solutions, insurance management services and technology platforms for all property and casualty markets, including commercial property, workers’ compensation, and auto/liability. We offer complex loss adjusting, technical services, third-party administration, and managed care programs with specialization in catastrophic, aviation, energy, and marine claims. With over 100 years of expertise at our core, we offer a comprehensive suite of solutions across all lines of business to help our clients manage risk.

• Own the full denial and rejection management workflow — analyze, resolve, and resubmit. • Identify patterns in claim failures and implement corrections to prevent recurrence. • Communicate directly with insurance companies to dispute denials and negotiate resolutions. • Monitor aging accounts and follow up aggressively on unpaid or underpaid claims. • Track and report on key RCM metrics (denial rate, days in AR, collection rate). • Collaborate with billers to catch upstream issues before they become denials. • Support provider credentialing processes as needed.

• Analyzing and processing Auto, GL, UI/UIM & PIP claims through well-developed action plans to an appropriate and timely resolution by investigating and gathering information to determine the exposure on the claim. • Negotiating settlement of claims within designated authority. • Communicating claim activity and processing with the claimant and the client. • Reporting claims to the excess carrier and responding to requests of directions in a professional and timely manner.