Clinical Auditor I-Nurse

WellSense Health Plan

140d•$64,000 - $93,000•Remote

About The Position

The Clinical Auditor I performs detailed, retrospective chart audit review, comparing medical documentation with paid charges. The Clinical Auditor I is a liaison and resource between WellSense Health Plan and external providers, working collaboratively with a diverse group, including management, physicians, clinical and non-clinical personnel. While verifying billed charges on paid claims, the auditor utilizes the WellSense policies and industry standard coding rules.

Requirements

Bachelor's degree in nursing or an equivalent combination of education, training, and experience is required OR Licensed Clinical Social Worker, Licensed Marriage Family Therapist or Licensed Mental Health Counselor
Minimum of two years of experience in case management, utilization review or claims auditing with a minimum of two years of clinical experience in an acute care setting required.
Valid license as a Registered Nurse, Licensed Clinical Social Worker, Licensed Marriage/Family Therapist or Licensed Mental Health Counselor is required.
Successful completion of pre-employment background check
Ability to relate and communicate positively, effectively, and professionally.
Ability to work independently and as a member of a team.
Detail oriented with analytical and problem-solving skills.
Ability to successfully organize and manage projects.
Excellent proof reading and editing skills.
Proficient oral, written and presentation skills.
Ability to work well under pressure and respond to changing needs and complex environments.
Strong working knowledge of Microsoft Office products.

Nice To Haves

Coding Certification preferred – CPC or CCS certification
Knowledge of CPT, ICD-10, and HCPCS coding is preferred.
Prior External Auditing and/or Medical Record Review experience is preferred.
Claims processing experience a plus.

Responsibilities

Utilizes basic knowledge of CPT, ICD-10, and HCPCS codes to verify billed hospital, physician and ancillary services against medical record documentation.
Research CPT codes to clarify coding issues, as required
Assesses provider coding for accuracy and confirms charges match the provider’s claim based on clinical documentation.
Outpatient, professional, ancillary claim reviews ensure billing and payment accuracy in alignment to medical records, policy adherence, contract adherence, and benefit coverage
Determines payment compliance per WellSense clinical and reimbursement policies.
Identifies documentation and billing issues during the review process.
Identify possible fraud and abuse, document billing errors, and benefit cost management and savings opportunities. Refer cases to the SIU or Third-Party Liability team when appropriate for further investigation.
Documents audit findings and meet with provider representatives to discuss.
Responds to amendment documentation and finalizes all audits, processing recoveries of unsupported charges consistent with WellSense reimbursement methods.
Meets position productivity level and provides a daily update.
Identifies potential quality of care or utilization issues and reports to management.
Communicates with providers. Prepares documentation, responds to emails and phone calls. Ensures that communicated audit denial rationale is clear, concise, and accurate.
Identifies audit trends and makes recommendations for potential audit projects.
Maintains an established level of claims adjustment quality.
Updates clinical audit guidelines and protocols