Claims Quality Analyst - Wellfleet Insurance : Job Details

Wellfleet, a Berkshire Hathaway company, delivers customer-centric accident and health insurance, with quality service and uncompromising ethics. Wellfleet works to protect people against risk throughout every stage of life from grade school to college to the workplace.

Founded in 1993 as Consolidated Health Plans (CHP), Wellfleet, headquartered in Springfield, Mass., is one of the nation's leading providers of health and accident insurance products to the higher education market.

The Claims Quality Analyst is responsible for claims quality review practices and processes to facilitate sustainable, measurable, continuous process improvement at the individual and department level that results in high quality claim handling, improved financial performance and increased customer satisfaction, while consistently meeting internal control standards. Perform claims system plan configuration audits, pre-payment claim reviews as well as post-payment reviews as needed, assist in the summarization of review metrics and findings while providing support to the education and training process for the claims department.

• Interact with other claims quality analysts on pre-payment and post-payment claim reviews to ensure validity and accuracy of claims as well as the timeliness of reviewed claims
• Audit system configuration of benefit plans against plan documents and report any discrepancies
• Perform pre-payment claim review for Wellfleet TPA's claims in excess of authority limit
• Serve as SME on LuminX claims processing; maintain LuminX audit parameters to meet internal and industry standards for claim review levels
• Report claims review results to the Claims Department; including detailed analysis of errors within required timeframe and support training/education efforts to reduce Claims Specialist processing errors
• Perform testing tasks and document findings on all completed projects, in coordination with the Claims Configuration & Quality Assurance Manager
• Coordinate with and provide detailed claim information to High Dollar review team
• Identify trends of claim errors and work with claims and plan configuration to establish process improvement methods
• Perform other duties as assigned

• Bachelor's degree in healthcare insurance or related field or 5+ years of equivalent experience in the field
• Demonstrates proficiency and understanding of medical terminology, ICD 10 codes, CPT/HCPC procedure codes, plan documents, claim terminology and state and federal regulations
• Experience with LuminX or other claims systems
• Claim audit or extensive claim processing experience required
• Ability to demonstrate excellent communication skills both verbally and written and foster productive working relationships
• Organizational skills to perform detail-oriented tasks and balance a variety of responsibilities both independently and as part of a team
• Strong analytical, judgement/critical thinking and problem-solving skills
• Experience with Microsoft Office Suite products
• Data mining/query/process flow tools (e.g., Access, SQL, ACL, Visio) preferred
• Ability to prioritize tasks and projects to meet deadlines

Why Wellfleet?

Here at Wellfleet, we foster a culture of growth that enables engaged and high-performing professionals to be empowered to deliver our mission and vision.

Our employees are a team devoted to providing customer service that exceeds expectations of our members and clients. Successful team members continually look for ways to improve product delivery and value.

Wellfleet offers a competitive compensation package and comprehensive benefits package including life, health and dental, vision, 401K retirement plan, short- and long-term disability coverage, flexible/dependent care spending account, tuition reimbursement, and business casual dress.

Are you interested in exploring a career at Wellfleet? Explore our open positions.