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
Claims Quality Inspector
Location
United States
Posted
2 days ago
Salary
$20 - $28 / hour
Seniority
Mid Level
Job Description
Claims Quality Inspector
WellSense Health Plan
Role Description 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. Qualifications - High School Diploma or GED required - Bachelor’s degree and/or Claims adjudication or medical billing/coding certification preferred - 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 - Prior experience within the Medicare, Medicaid, or other regulated Managed Care payer environment preferred - Prior experience with coordination of benefits or subrogation preferred - Familiarity with Facets claims administration platform preferred - Prior Enrollment quality auditing experience preferred - Pre-employment background check required Requirements - 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 Benefits - Full-time remote work - Competitive salaries - Excellent benefits - Generous total compensation including 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 - 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 cited 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, inconsistencies 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 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.
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