Claims Quality Inspector

WellSense Health Plan•Boston, MA

4d•$20 - $28•Remote

About The Position

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.

Requirements

High School Diploma or GED 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
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
Pre-employment background check

Nice To Haves

Bachelor’s degree and/Claims adjudication or medical billing/coding certification preferred
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

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, 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