Claims Compliance Analyst

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.

T he Claims Compliance Analyst is responsible for fully understanding Wellfleet’s policies and procedures, deep knowledge of the claim process with the ability to process claims. The ideal candidate is responsible for implementation, auditing, and execution of compliance activities as they relate to claims. They will work closely with the Compliance Team to assess compliance risks and controls and implement and communicate new regulations that affect the claims team.

In this role, you will…

• Proficient in navigating the LuminX claim system
• In depth understanding of the claim adjudication process:
• Process claims in accordance with the plan document in a timely and accurate manner > Perform detailed analysis of medical treatment submitted for payment > Investigate and administer the terms of coverage
• Detailed understanding of State/Federal insurance regulations and mandates
• Maintain product/system knowledge and be a subject matter expert
• Ability to work independently with minimal questions and find resolution to problems
• Work with Compliance/Legal to understand and implement new and/or existing regulations utilizing RegEd application
• Development, execution and auditing of Claim related compliance items (e.g. risk assessment, testing & monitoring of key regulations, policies & procedures, assist with exam preparation, issue reporting and escalation, training program, corrective actions)
• Implementation and monitoring of claim related compliance policies and procedures
• Work within RegEd to review assigned tasks and implement new laws, rules, and regulations
• Assistance in reviewing claim related tasks for market conduct exams
• Create job aids for regulatory items impacting claims that require special handling
• Participate in recurring compliance meetings
• Ability to review claim related compliance reports to ensure accuracy
• Scrub prompt pay reports to accurately determine clean claim date and proper penalties/interest
• Handle claim adjustments related to regulatory requirements
• Communicates issues or concerns etc. to Manager
• Perform other duties as assigned, or as situation dictates
  
  
  

We are looking for candidates with…

• Minimum of 5 years health care claim processing experience required.
• Solid understanding of Wellfleet’s policies and procedures.
• Ability to design, conduct and report on compliance self-monitoring activities.
• Ability to digest and understand laws/regulations as interpreted by Legal Department.
• Ability to assess, prioritize and communicate risk within Claim Operations.
• Strong organizational skills and attention to detail.
• Strong written and verbal communication skills.
• Excellent presentation and interpersonal skills.
• Ability to work in a fast-paced environment, think quickly, meet deadlines, and adapt to various situations.
• Ability to understand complex problems, identify root causes, and remain goal-oriented within a dynamic environment.
• Ability to p rioritize multiple work assignments simultaneously.
• Exhibits strong work ethic.
• Strong analytical skills, with the ability to effectively identify, communicate, and address potential issues.
• Ability to work independently and as a team player.
• Ability to work effectively with peers, as well as business areas at all levels of the organization.
• Strong commitment to compliance & ethics.
  
  
  

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.

General:

Wellfleet is part of the MedPro Group family. As such, all Wellfleet team members are employees of MedPro Group Inc. We are an Equal Opportunity Employer. The annual gross base salary range is $60,000 to $70,000. This range anticipates the low and high end of the salary for this position. Actual salaries will vary and are based on factors such as a candidate’s qualifications, skills and competencies. Salary is one component of Wellfleet’s total compensation and benefits package, which includes medical, vision and dental insurance options, life and accident insurance, 401(k), and short-term and long-term disability insurance. For a more detailed overview, visit our careers website at: wellfleetinsurance.com/about/careers.