Claims Resolution Specialist

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:

This position is responsible for accurate and timely research of all claim dispute inquiries, timely processing of adjustments and acts as a claims liaison between internal and external partners and helping with other Claims-related initiatives. Responsible for the accurate and timely processing of internal inquiries to the Claims Resolution team. Must complete duties with a high level of detailed quality and professionalism.

Our Investment in You:

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

Key Functions/Responsibilities:

• Performs review of previously processed claims coming into the CRU to determine if additional information is required or if the documentation present is sufficient to determine if claim requires reprocessing.
• As part of claim review process use multiple systems to confirm claims were processed accurately based on contracts, medical policy and other policies and procedures, review accumulators and calculations of deductibles and maximums as applicable.
• Investigate and perform adjustments of complex claims.
• Determines root cause of claim processing errors and reports findings to leadership for further investigation and to prevent future errors.
• Provides verbal or written responses to inquiries from internal business areas. Appropriately documents all interactions according to established department procedures.
• Ensures data is entered into the appropriate case tracking system to ensure all pertinent information is recorded for internal tracking and monitoring.
• Provides feedback on opportunities found during review for remedial training.
• Serves as the subject matter expert for the team.
• Manages complex claims projects / large volumes of adjustment requests.
• Will present data and analysis within regular work group meetings.
• Maintain timely resolution of inquiries according to established timeframes.
• During peak claim volumes, may provide back-up on an as needed basis to the Claims Department
• Other duties as assigned

Supervision Exercised:

• Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff.

Supervision Received:

• Close supervision received daily

Qualifications:

Education Required:

• High School Diploma (or equivalent/ GED)

Education Preferred:

• Associate degree or some college coursework

Experience Required:

• 2 years of claims processing or other equivalent health plan experience

Experience Preferred/Desirable:

• Two or more years experience in a managed care claims environment as a claims adjudicator, senior staff member or other equivalent experience required. Experienced with Facets claims processing.

Required Licensure, Certification or Conditions of Employment:

• Successful completion of pre-employment background check

Competencies, Skills, and Attributes:

• Experience with Facets system
• Familiarity with UB04's and CMS 1500's
• Experience with Microsoft Excel (ability to create, edit, filter and sort through spreadsheets)
• Experience with Microsoft Word (ability to create and edit documents)
• Experience with Microsoft Outlook (ability to send/receive emails and calendar invites)
• Understand and maintain HIPAA confidentiality and privacy standards when completing assigned work
• Proficiency with computer and Windows PC applications, which includes the ability to learn new and complex computer system applications
• Navigate across various computer systems to locate critical information.
• Attention to detail to ensure accuracy, which will support timely processing of the member's claim.
• Strong communication skills (internally and externally).
• Independent problem solving ability
• Ability to work with minimal supervision while meeting deadlines.

Working Conditions and Physical Effort:

• Ability to work OT during peak periods.
• Regular and reliable attendance is an essential function of the position.

Telecommuting Requirements

• Required to have a dedicated work area established that is separated from other living areas and provides information privacy
• Ability to keep all company sensitive documents secure (if applicable)
• Must live in a location that can receive an approved high-speed internet connection or leverage an existing high-speed internet service.

Compensation Range:

$22.35 - $32.45

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. 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, 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.

Note: This range is based on Boston-area data, and is subject to modification based on geographic location.

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.

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