Clinical Oversight & Claim Review Nurse, Anywhere

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 Clinical Oversight and Claim Review Nurse contributes to the clinical operations of Wellfleet’s Student Health division by applying nursing expertise to make benefit determinations on claims, review high-dollar claims for cost-containment and case management opportunities, oversee utilization review and case management vendor performance and regulatory compliance, review medical records and coding to support Fraud Waste and Abuse (FWA) activities, maintain payment and utilization review guidelines, guide care coordination efforts, and support the delivery of cost-effective, high-quality healthcare for student members. In this role, you will… • Monitor and respond to clinical inquiries received via email, ensuring timely and accurate communication • Assist in the review and evaluation of high-dollar medical claims for accuracy, medical necessity under the supervision of the Chief Medical Officer, and cost-effectiveness • Apply clinical nursing knowledge and coding expertise to review claims and benefit determinations • Review medical records and coding to support fraud, waste, and abuse activities • Execute delegated activities under the Quality Management Program, including facilitation of meetings, documentation, and coordination with participants • Oversee utilization management and case management vendor performance and regulatory compliance • Perform data analysis needed for vendor oversight • Evaluate applicable insurance regulations for business impact and ensure compliance across clinical operations • Develop and maintain job aids and other documentation needed to support regulatory compliance • Proactively identify cost-containment and quality improvement opportunities and recommend potential solutions • Triage and support care coordination activities by collaborating with case managers, providers, and vendors to ensure effective communication and continuity of care • Manage case management workflows by evaluating the appropriateness of referrals, approving/denying/submitting/closing cases as needed, and monitoring case management reports to ensure timely interventions and positive outcomes • Document, track, and analyze activities as necessary to support operational performance and quality metrics • Compile research information to support internal review guidelines and maintain payment and utilization review guidelines in coordination with workgroups • Identifies opportunities for process improvement and develop actionable plans to enhance operational efficiency and quality • Contribute to strategic initiatives and innovative programs that support the company’s growth and enhance student health outcomes through the development and maintenance of impactful projects • Perform other duties as assigned. We are looking for candidates with… • Possess and maintain an active registered nurse (RN) licensure • Minimum of 3+ years of clinical care experience and minimum of 3+ years experience in utilization review and/or case management • 1+ years of health insurance experience preferred • Current AAPC or AHIMA certification for Medical Coding preferred • Demonstrated advanced knowledge of utilization management and/or case management • Experience with assessing and addressing operational impact of regulatory requirements preferred • Excellent written and verbal communication skills • Strong interpersonal skills with the ability to collaborate effectively with both internal team and external partners • Outstanding organizational, detail oriented and time management skills, including thorough and complete follow-up on all time sensitive items • Possess excellent clinical, problem solving, and critical thinking skills with proven ability to identify and address complex issues • Demonstrated ability to efficiently manage multiple assignments and prioritize tasks in a fast-paced environment to meet deadlines • Self-motivated with the ability to work independently, with very little supervisory direction • Proficient with MS Office products, including Outlook, Teams, Excel, Word, and PowerPoint. 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 $90,000 to $100,000. 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. #LI-KS1 #LI-Remote Apply tot his job Apply To this Job