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.
Join our rapidly growing and fast paced health insurance organization in the Springfield area. This position is responsible for reviewing claims, interpreting plan language, and ensuring that all claims contain the required documentation to support the claim determination. This requires applying the appropriate contractual provisions; plan specifications of the underlying plan document; professional case management resources; and claims practices, procedures, and protocols to the medical facts of each claim to decide on reimbursement or denial of a claim.
The ideal candidate is accountable for developing, coordinating, and implementing a plan of action for each claim accepted to ensure it is managed effectively and all cost containment initiatives are implemented in conjunction with the clinical resources.
In this role, you will…

• Determine, on a timely basis, the eligibility of assigned claim by applying the appropriate contractual provisions to the medical facts and specifications of the claim
• Apply the appropriate contractual provisions from the underlying plan document/policy especially with regards to eligibility and exclusions
• Maintain claim mailbox and meet departmental metrics
• Have an awareness of industry claim practices
• Explain rationale of claim decision based on review of the contractual provisions and plan specifications and the analysis of medical records
• Knowledge of legal risk and regulatory/statutory guidelines HIPPA, privacy, Affordable Health Care Act, etc.
• Understand where, when and how professional resources both internal and external (e.g. medical, investigative and legal) can add value to the process
• Establish cooperative and productive relationships with professional resources
• Perform other duties as assigned

We are looking for candidates with…

• Bachelor's degree preferred
• A minimum of five years’ experience processing first dollar medical claims
• Demonstrated ability to independently and as a part of a cohesive team
• Strong written and verbal communication skills
• Significant knowledge of Stop Loss industry preferred, but not required
• Demonstrated success in handling high attention to details, and familiarity with investigatory procedures and resource knowledgebase as needed.
• Ability to work in a fast-paced environment; flexibility to handle multiple priorities while maintaining a high level of professionalism
• Overall knowledge of health care industry
• Proficiency using the Microsoft Office suite of products

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.

Job Type: Full-time

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