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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:
Supervision Received:
Qualifications:
Education Required:
Education Preferred:
Experience Required:
Experience Preferred/Desirable:
Required Licensure, Certification or Conditions of Employment:
Competencies, Skills, and Attributes:
Working Conditions and Physical Effort:
Telecommuting Requirements
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.
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.Full Time
$55k-69k (estimate)
04/18/2024
04/29/2024
The job skills required for Claims Resolution Specialist include Problem Solving, Attention to Detail, Leadership, Analysis, Communication Skills, Futures, etc. Having related job skills and expertise will give you an advantage when applying to be a Claims Resolution Specialist. That makes you unique and can impact how much salary you can get paid. Below are job openings related to skills required by Claims Resolution Specialist. Select any job title you are interested in and start to search job requirements.
The following is the career advancement route for Claims Resolution Specialist positions, which can be used as a reference in future career path planning. As a Claims Resolution Specialist, it can be promoted into senior positions as a Claims Adjuster III that are expected to handle more key tasks, people in this role will get a higher salary paid than an ordinary Claims Resolution Specialist. You can explore the career advancement for a Claims Resolution Specialist below and select your interested title to get hiring information.