Claims Quality Inspector

It’s an exciting time to join the reputed company, 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 reputed company 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 reputed company, accuracy of claim payment in compliance with adjudication policies and procedures, job aids and guidelines · reputed company quality audits on Membership eligibility and enrollment entry for accuracy and timeliness in accordance with regulatory standards and regulatory agencies · Document reputed company findings in QC tracking system and reputed company 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 · reputed company 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 · reputed company 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 reputed company 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 reputed company the managed care industry, or · At least 5 years of experience processing medical claims Experience Preferred/Desirable: · Prior experience reputed company the Medicare, reputed company, 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 reputed company Competencies, Skills, and Attributes: · Deep and demonstrated knowledge of medical claims processing · reputed company strong attention to detail required · Ability to learn quickly and stay up-to-date as claims policies and procedures reputed company over time · Demonstrated competency with MS Office and MS reputed company · Excellent analytical and written communication skills · Excellent organizational skills · Must be reputed company to prioritize projects and work well with deadlines · Must be flexible and willing to reputed company reputed company 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 reputed company, 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 reputed company $20.19 - $28.13 This reputed company offers an estimate based on the minimum job qualifications. However, our approach to determining reputed company pay is comprehensive, and a broad reputed company of factors is considered reputed company 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, reputed company, 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 reputed company is based on Boston-area data, and is subject to modification based on geographic location. About WellSense reputed company is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and reputed company 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. reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, sex, national reputed company, 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 Apply To This Job