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WellSense Health Plan

WellSense Health Plan is a nonprofit health insurance company. As an employer, the company strives to foster a fast-paced, goal-motivated, and supportive culture for its team membe

Clinical Auditor I

Location

United States

Posted

3 days ago

Salary

$64K - $93K / year

Seniority

Mid Level

No structured requirement data.

Job Description

Clinical Auditor I

WellSense Health Plan

Role Description The Clinical Auditor I performs detailed medical record audit review and analysis of the health plan’s outpatient, professional and ancillary claims to ensure that all reimbursement to the provider is paid accurately and ensuring adherence to regulations, internal policies and best practice of patient care. Qualifications - Bachelor's degree in nursing or an equivalent combination of education, training, and experience is required. - Two years CM, UM, claims auditing or other clinical health insurance role. - Two years minimum RN experience in acute care setting. - Behavioral Health and/or Inpatient DRG experience required. Requirements - Valid Registered Nurse License required. - Coding Certification Preferred - CPC or CCS certification. - Basic familiarity with CPT, ICD-10 and HCPCS coding is preferred. - Claims processing experience is preferred. Benefits - Full-time remote work. - Competitive salaries. - Excellent benefits. - Generous total compensation that includes 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. Key Functions/Responsibilities - Analyze patient records, treatment plans, and medical billing documents to ensure accuracy, completeness, and strict compliance with healthcare standards and regulations. - Verify that procedures and diagnoses are accurately coded using appropriate CPT, HCPCS, and ICD-10 codes. - Check for consistent documentation across patient records, confirming that all entries adhere to regulatory mandates, internal policies, contract stipulations, and benefit coverages. - Identify any documentation or billing discrepancies during the review process. - Based on audit findings, regularly update and refine clinical audit guidelines and protocols. - Use statistical and analytical methods to examine clinical data. - Methodically review data to identify discrepancies and irregularities. - Analyze data trends to determine potential areas of risk. - Continuously monitor and document recurring patterns or anomalies in clinical data. - Provide well-founded recommendations for new audit projects. - Conduct both scheduled and ad hoc audits in strict accordance with established guidelines and internal processes. - Develop comprehensive audit reports that clearly outline all findings. - Play a supportive role in the amendment and appeals process. - Finalize all audits by ensuring that all findings are documented. - Collaborate closely with clinical staff, audit coordinator, and other members of the audit team. - Maintain active communication with providers by preparing precise documentation. - Ensure that any audit denial rationale is clearly communicated. - Continuously monitor evolving federal and state healthcare regulations. - Evaluate clinical and reimbursement activities to determine payment compliance. - Proactively identify potential fraud and abuse. - Refer cases to the Special Investigations Unit (SIU) or the Third-Party Liability team. - Detect potential quality of care or utilization issues during audits. - Assist in educating clinical personnel on documentation requirements and audit practices.

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