Claims Quality Inspector
Location: Remote (United States)
About WellSense Health Plan:
WellSense Health Plan is a nonprofit health insurance provider serving over 740,000 members across Massachusetts and New Hampshire through Medicare, Medicaid, and Individual & Family plans. With over 25 years of experience, we are committed to delivering high-quality healthcare solutions tailored to the diverse needs of our members.
Job Summary:
The Claims Quality Inspector is responsible for reviewing adjudicated claims and enrollment entries for accuracy and compliance with established corporate guidelines. The ideal candidate will have strong knowledge of claims processing and enrollment rules and will support continuous improvement in operational quality.
Key Responsibilities
Claims Review & Adjudication:
Conduct accurate and timely quality reviews of claims, ensuring compliance with adjudication policies, job aids, and guidelines.
Perform quality audits of membership eligibility and enrollment entries.
Documentation & Reporting:
Document findings in the QC tracking system and communicate error determinations clearly.
Update reference materials and QA documents to ensure consistency and accuracy.
Collaboration & Support:
Collaborate with team members to meet departmental goals.
Provide assistance in the rebuttal process and support internal audits.
Identify and document workflow issues and suggest improvements.
Process Improvement & Compliance:
Support quality initiatives by recommending new process documentation and materials.
Monitor workflow processes for defects and potential risks.
Ensure adherence to policies, procedures, and audit specifications.
Special Projects:
May be assigned special projects and business initiatives by management.
Qualifications
Education:
High School Diploma or GED required.
Bachelor’s degree or Claims adjudication/medical billing/coding certification (preferred).
Experience Required:
At least 2 years of experience in Claims or QC/Inspector roles within the managed care industry, or
At least 5 years of experience in medical claims processing.
Experience Preferred:
Prior experience within Medicare, Medicaid, or other regulated Managed Care environments.
Familiarity with Facets claims administration platform and Enrollment quality auditing.
Competencies, Skills, and Attributes
Attention to Detail:
Strong focus on accuracy in claims processing and audits.
Analytical & Organizational Skills:
Ability to analyze and document findings effectively.
Excellent organizational and time-management skills.
Communication Skills:
Strong written communication and the ability to explain complex issues clearly.
Adaptability & Flexibility:
Ability to learn quickly and adapt to changing policies and procedures.
Capable of balancing multiple priorities in a fast-paced environment.
Working Conditions
Remote Work: Full-time remote position.
Business Hours: Must be available to work East Coast business hours (9 AM – 5 PM, Monday to Friday).
Overtime: Ability to work overtime during peak periods.
Attendance: Regular and reliable attendance is essential.
Why Join WellSense?
Remote Flexibility: Enjoy the convenience of working from home.
Competitive Benefits: Comprehensive salary and benefits package.
Inclusive Culture: WellSense is committed to diversity and inclusion in staffing and member services.
Equal Opportunity Employer:
WellSense is an equal opportunity employer, committed to diversity and inclusion. Qualified applicants are considered without regard to race, gender, disability, or veteran status.
Apply Today:
Join a team dedicated to improving healthcare outcomes. Visit WellSense Careers to apply.
Important Employment Offer Scam Warning:
Beware of employment scams. WellSense only accepts applications through our website and does not conduct interviews or offer employment via text or social media.
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