Provider Relations Consultant

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.

Job Summary:

Acts as the primary liaison between Provider Relations Consultants and internal Plan departments such as Claims, Benefits, Audit, Member and Provider Enrollment and Clinical Services to effectively identify and resolve claim issues.  Works closely with the leadership team to identify issues and report trends. 

Our Investment in You:

·       Full-time remote work

·       Competitive salaries

·       Excellent benefits

Key Functions/Responsibilities:

·       Investigate, document, track, and assist with claims resolution.

·       Interact with various operational departments to assure accurate and timely payment of claims in accordance with the plan's policies and procedures.

·       Identify system changes impacting claims processing and work internally on resolution.

·       Identify systematic issues and trends and research for potential configuration related work.

·       Analyze trends in claims processing and assist in identifying and quantifying issues.

·       Run claim reports regularly to support external provider visits.

·       Develop and enhance our physician, clinician, community health center and hospital relationships through effective business interactions and outreach.

·       Act as liaison for all reimbursement, issues with providers.  Facilitates resolution of complex contractual and member/provider issues, collaborating with internal departments as necessary.

·       As needed, provides general education and support on WellSense products, policies, procedures and operational issues.  

·       Manages flow of information to and from internal departments to ensure communication regarding Plans changes and updates.

·       May outreach to providers according to Plan initiatives.

·       Facilitates problem resolution.  Initiates Plan interdepartmental collaboration to resolve complex provider issues.

·       Identifies system updates needed and completes research related to provider data in Onyx and Facets.

·       Processes reports as needed to support provider education, servicing, credentialing and recruitment.

·       Ensures quality and compliance with State Agencies and NCQA. 

·       Other responsibilities as assigned.

·       Understanding and implementation of Plan polices & procedures

·       Regular and reliable attendance is an essential function of the position.

Supervision Exercised:

·       None

Supervision Received:

·       Indirect supervision is received weekly.

Qualifications:

Education:

·       Bachelor’s degree in Business Administration, related field or an equivalent combination of education, training and experience is required.

Experience:

·       2 or more years of progressively responsible experience in a managed care or healthcare environment is preferred.

·       Experience with Medicare and Medicaid Reimbursement Methodologies.

·       Understanding of provider coding and billing practices.

Certification or Conditions of Employment:

·       Pre-employment background check.

·       Must have valid drivers license and access to a car.

Competencies, Skills, and Attributes:

·       Experience with ICD-10, CPT/HCPCS Codes, and billing claim forms.

·       Ability to work as a team member, to manage multiple tasks, to be flexible, and to work independently and possess excellent organizational skills.

·       Proven expertise utilizing Microsoft Office products.

·       Effective communication skills (verbal and written).

·       Strong follow-up skills.

·       Proficient in multi-tasking.

·       Ability to set and manage priorities.

Working Conditions and Physical Effort:

·       Must be willing to travel significantly to local communities to meet business needs up to 50% of the time

·       Ability to work in a fast-paced environment

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. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees