Manager Clinical Audit

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:

The Manager Clinical Audit provides oversight and leadership of the Clinical Audit Team within the Payment Integrity Department. The Clinical Audit team performs detailed medical record and chart audit review of the health plan’s claims to ensure that all reimbursement to the provider is paid accurately. The Clinical Auditors are a liaison and resource between the health plan and external providers, working collaboratively with a diverse group, including management, physicians, clinical and non-clinical personnel. 

Our Investment in You:

·       Full-time remote work

·       Competitive salaries

·       Excellent benefits

Key Functions/Responsibilities:

• Oversees Clinical Audit program of both internal and external entities responsible for reviewing medical record documentation to ensure all reimbursement to providers is accurately adhering to coding regulations, reimbursement policies, medical policies, regulatory requirements and provider contractual obligations.
• Leads a program that significantly improves the accuracy of medical billing and coding practices, supports improved provider billing and ensures correct financial reimbursement
• Responsible for tracking claims audit inventory and claim aging to ensure accurate and timely completion of audits and processing of claims
• Ensures both individual and program productivity, financial and quality targets are established and measured periodically. Leads the development of dashboards and key performance indicators to inform the organization of performance against targets
• Evaluates and optimizes audit workflow processes to continually increase the program’s return on investment. Includes evaluation and optimization of software/technology within the audit workflow process
• Provides supplier oversight of all outsourced Clinical Auditing to ensure quality, accuracy, and appropriate financial results from any suppliers completing Clinical Audits on WellSense’s behalf
• Partners with senior leadership in developing, implementing, and communicating short and long-range plans, goals, and objectives. Aligns team goals with the organization’s vision and strategy

• Identifies payment integrity issues, opportunities, and effective solutions and leads efforts to improve processes and deliver results. Navigates the organization and drives solutions to clinical, operational or business challenges; effectively using data to make recommendations and decisions
• Works collaboratively and cross functionally with the health plan’s medical directors and other clinical teams such as utilization management and care management
• Handles management-level responsibilities for staff, including setting clear goals and performance expectations, performance reviews, employee development, hiring, addressing performance issues, coaching, counseling, and retention. Develops leaders and participates in talent management activities
• Helps to determine appropriate staffing levels and resource needs, creates and manages department and/or project budgets, allocates resources
• Ensures compliance with and participates in legislative initiatives and mandates including but not limited to federal, HIPAA, state mandates and URAC. Stays informed about changes in coding regulations, policies, and procedures to ensure organizational compliance
• Knowledge of CPT, ICD-10, and HCPCS codes to verify billed hospital, physician and ancillary services against medical record documentation. Researches CPT codes to clarify coding issues, as required
• Completes audits as needed on inpatient, outpatient, professional, and ancillary claims to assess provider coding for accuracy and confirm charges are accurate based on clinical documentation. Reviews clinically complex claims, high dollar claims and multi-claim episodes of care. Determines payment compliance per clinical and reimbursement policies.
• Reviews audit program data to identify trends in documentation and billing issues. Identifies potential quality of care or utilization issues and reports to management
• Reviews audit program data to identify possible fraud and abuse, repeat billing errors, and benefit cost management and savings opportunities.  Refer cases to the SIU or Subrogation team when appropriate for further investigation
• Ensures that all program audit findings documentation is accurately reported both internally and externally in regulatory reporting
• Supports amendment/appeals process and engages medical directors and additional stakeholders as needed to resolve appeals
• Participates in in-person and/or virtual meetings with providers regarding escalated issues and/or opportunities for billing, coding, and documentation improvement identified in the audit process
• Trains staff on audit protocols and processes
• Participates in special projects and project initiatives
• Develops and maintains all Clinical Audit guidelines, policies, procedures and protocols
• Designs Audit Quality Review guidelines and protocols. Performs quality control/quality assurance audits to ensure both individual auditor and team quality objectives are met
• Other duties as assigned

Supervision Exercised: 

·       Supervises 5-7 FTEs

Supervision Received: 

·       Direct supervision is received weekly.

Qualifications: 

Education Required: 

• Associates or Bachelor’s degree in Nursing required

Education Preferred:

Experience Required:

·       5 years minimum clinical claim/medical record auditing

·       2 years minimum RN experience in acute care setting

·       Experience leading teams, initiatives, process improvements, or program management

Experience Preferred/Desirable:

·       Health Insurance, preferably Medicaid and Medicare experience

Required Licensure, Certification or Conditions of Employment: 

·       Coding Certification Required - CPC or CCS certification

·       Valid Registered Nurse License required

·       Successful completion of pre-employment background check

Competencies, Skills, and Attributes: 

• Can navigate ambiguous situations and balance competing demands and deliver results in times of constant change
• Knowledge of health insurance industry trends and technology
• Clinical terminology
• 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.
• Strong 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.
• Ability to interact within all levels of the organization as well as with external contacts
• Demonstrated ability to successfully plan, organize and manage projects.
• Demonstrated ability to compile, format, analyze, and present data to a variety of individuals, including hospital representatives, physicians, and management.
• Demonstrated ability to develop and lead high performing teams and direct vendors.
• Strong communication and facilitation skills with all levels of the organization, including the ability to resolve issues and build consensus among groups of diverse stakeholders.
• General business acumen including understanding of data analysis and decision making.
• Demonstrated ability to help create and execute operationally efficient and cost-effective programs and drive results across internal teams and/or external vendors.
• Extensive knowledge of state regulatory requirements, CMS, and demonstrated ability to manage compliant operations.

Working Conditions and Physical Effort:

• Regular and reliable attendance is an essential function of the position.
• Work is normally performed in a typical interior/office work environment.
• No or very limited physical effort required. No or very limited exposure to physical risk.  

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.