Manager, Member and Provider Service

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.

The Manager is responsible for managing all aspects of the Member and Provider Services Department, including but not limited to staff development and training; service level adherence; policy and workflow development; and corporate, regulatory and accreditation reporting. The Manager is responsible to ensure accurate, timely and courteous response to Member and Provider inquiries and coordination of member outreach and claims resolution activities.

Our Investment in You:

• Full-time remote work
• Competitive salaries
• Excellent benefits

Key Functions/Responsibilities:

General

• Accountable for the delivery of prompt courteous service and accurate information in responding to all Member and Provider inquiries.
• Participates in the recommendation, development and implementation of short and long term service strategies that improve Member and Provider satisfaction.
• Responsible for the daily analysis of call volumes, monitoring and adjusting staff resources to meet inbound and outbound call demands and performance goals and maximize efficiency (e.g. maintain appropriate staffing level relative to call volume); ensures compliance with corporate and departmental standards and BMCHP’s contracts.
• Responsible for the maintenance and monitoring of key indicator reports to proactively identify and communicate existing and potential Member and Provider Service issues and ensures timely delivery of key indicator reports (and communication of identified issues) to operations leadership according to schedule.
• Develops policies and procedures toward improved service delivery and customer satisfaction and quality and consistency of customer interactions; establishes, maintains and refines intradepartmental and interdepartmental processes and procedures to support Member and Provider Services work processes across product lines.
• Manages supervisors through coaching, professional development, problem resolution, performance evaluation, and related management and supervisory activities; recruits, motivates and retains a high caliber of team members.
• Manages the day-to-day relationship with the language interpretation vendor and other vendors, as applicable.
• Responsible for coordination and administration of Member Advisory Committees.
• Responsible for all Member Services contractual, regulatory and accreditation reporting. Responsible for maintenance, integrity and accuracy of member inquiry and call data.
• Supports and assists RFR responses and product implementations as needed
• Assists and participates in budget planning, including forecasting.

Supervision Exercised:

• Manages 4-6 direct reports and approximately 40-70 indirect reports.

Supervision Received:

• General supervision received weekly or as needed

Qualifications:

Education:

• Bachelor’s degree or an equivalent combination of education, training and experience, usually 6-7 years related experience in a managed care plan, is required.

Experience:

• Minimum of 5 years call center experience required.
• Minimum of 5 years at the supervisor and/or manager level.
• Minimum of 5 years experience in healthcare or managed care is required.

Preferred/Desirable:

• Comprehensive knowledge of applicable contract provisions and accreditation requirements, including but not limited to NCQA, MassHealth, Commonwealth Care, QHP and NH Care Management.
• Comprehensive knowledge of reimbursement, claims adjudication, and payment policies.
• Current knowledge of Facets, Witness, Avaya, CCMS, and all systems used by Member and Provider Services staff and management.

Certification or Conditions of Employment:

• Pre-employment background check

Competencies, Skills, and Attributes:

• Strong oral and written communication skills and ability to interact within all levels of the organization.
• Effective collaborative and proven process improvement skills.
• A strong working knowledge of Microsoft Office products.
• Demonstrated ability to successfully plan, organize and manage projects.
• Detail oriented, excellent proof reading and editing skills.

Working Conditions and Physical Effort:

• Regular and reliable attendance is an essential function of the position.
• Work is normally performed in a typical interior/office work environment.
• No or very limited exposure to physical risk.
• Travel to regional offices required.

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.