Clinical Auditor I

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 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.

Our Investment in You:

• Full-time remote work
• Competitive salaries
• Excellent benefits

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. Ensure that the coding reflects the clinical documentation accurately and complies with current guidelines.
• 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. This includes spotting errors, omissions, or inconsistencies that may affect reimbursement or patient care quality, and flagging these issues as needed.
• 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 that could indicate non-compliance with internal policies, contractual obligations, or regulatory mandates.
• Analyze data trends to determine potential areas of risk that might adversely affect patient care or disrupt the organization's operations.
• Continuously monitor and document recurring patterns or anomalies in clinical data.
• Based on the insights gathered, provide well-founded recommendations for new audit projects.
• Conduct both scheduled and ad hoc audits in strict accordance with established guidelines and internal processes. This involves planning and executing audit activities to ensure every clinical record is reviewed consistently while aligning with quality assurance benchmarks.
• Develop comprehensive audit reports that clearly outline all findings. Reports must detail discrepancies, note any process inefficiencies, and provide precise, actionable recommendations for improvement.
• Play a supportive role in the amendment and appeals process. This includes coordinating with providers to resolve discrepancies and ensuring the audit conclusions are fully and fairly reviewed.
• Finalize all audits by ensuring that all findings are documented, follow-up actions are clearly communicated, and the entire process meets the established timelines and productivity standards for the role.
• Collaborate closely with clinical staff, audit coordinator, and other members of the audit team on audit findings and questions.
• Maintain active communication with providers by preparing precise documentation, responding promptly to emails and phone calls, and offering detailed explanations of audit results.
• Ensure that any audit denial rationale is clearly, concisely, and accurately communicated.
• Continuously monitor evolving federal and state healthcare regulations along with industry standards by engaging in regular education and policy reviews. Ensure that all clinical documentation and audit processes are consistently aligned with current regulatory requirements and best practices.
• Evaluate clinical and reimbursement activities to determine payment compliance under WellSense clinical and reimbursement policies.
• Proactively identify potential fraud and abuse by scrutinizing clinical data, documenting billing errors, and highlighting opportunities to manage benefit costs and secure savings.
• When discrepancies or irregularities signal deeper issues, refer cases to the Special Investigations Unit (SIU) or the Third-Party Liability team.
• Detect potential quality of care or utilization issues during audits and promptly report these findings to management.
• Assist in educating clinical personnel on documentation requirements and audit practices to enhance compliance and overall patient care quality.

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 DRG experience required

Certification or Conditions of Employment:

• 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

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. 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