WellSense Health Plan is a nonprofit health insurance company serving members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances.
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.
The Provider Appeals Coordinator is responsible for managing the overall coordination, investigation, documentation and the resolution process of medical claims appeals and ensuring compliance with policies and procedures under company, MassHealth, Commonwealth Care contracts and NCQA standard guidelines.
Our Investment in You:
Full-time remote work
Competitive salaries
Excellent benefits
Key Functions/Responsibilities:
The Appeals Coordinator is competent in the following related responsibilities but may not be expected to be responsible for all of the functions simultaneously. The Appeals Coordinator may have a major focus on administrative appeals; while also providing clinical edit claims review support to the dept. Nurse Coordinator.
Maintains the Provider Appeals process and workflow toward process improvement; provider satisfaction and claims payment accuracy under MassHealth, Commonwealth Care contract requirements and NCQA accreditation guidelines where applicable
Establishes and ensures workflow continuity with the Plan in the areas of Claims Processing; Provider Servicing and Health Services
Responsible for the preparation and research of data and records required to assure timely processing of administrative appeals in compliance with company guidelines
Produces administrative appeals reports for management and nurse review, as well as ad hoc reports
Ensures the quality and organization of administrative appeal documentation
Provides claims review and interpretation of appropriateness of administrative appeal
Coordinates management of provider appeals with other departments and tracks through resolution
Ensures continuous improvement of the administrative appeals process and establishment of related workflows as needed in response to Plan policy and procedure or claims processing changes
Responds to, documents, investigates and facilitates the resolution of provider administrative appeals, including the writing, review, and approval of resolution letters
Identifies and communicates trends
Works with other departments to create and implement improvement plans
Qualifications:
Education:
Bachelor’s degree in Health Care Administration, related field or, an equivalent combination of education, training and experience is required
Certification in Medical Coding (CPC Certification) preferred
Experience:
2 or more years’ experience working in a managed care organization required
Experience with claims processing and appeals required
Knowledge of Medical Coding, Medical terminology, CPT‚ ICD9‚ and HCPCS codes required
Project Management experience highly desirable
Competencies, Skills, and Attributes:
Demonstrated ability to successfully plan, organize and manage projects within a managed care organization
Strong working knowledge of Microsoft Office products required
Detail oriented, excellent verbal and written communication skills essential
Ability to work in both team and independent settings at all levels of the organization
Good customer service skills essential
Experience working with diverse populations preferred
Knowledge of health care terminology helpful
Effective collaborative and proven process improvement skills
Strong oral and written communication skills; ability to interact within all levels of the organization
A strong working knowledge of Microsoft Office products
Demonstrated ability to successfully plan, organize and manage projects
Detail oriented, excellent proof reading and editing skills
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.