Provider Relations Consultant (Remote)

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 Provider Relations Consultant - NH will act 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. This individual will also work 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
• Provides general education and support on WellSense products, policies, procedures and operational issues as needed
• 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
• Understands and implements Plan polices & procedures

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:

• Must have valid driver’s 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:

• Travel up to 25%

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.