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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:

Responsible for managing assigned territory of professional, institutional and ancillary providers to develop and enhance relationships, making WellSense Health Plan their plan of choice.  Serves as the primary liaison between WellSense and key provider organizations, taking the lead and promoting collaboration within WellSense as it relates to provider satisfaction.  Manages territory of assigned network partnerships, that may include Special Kids Special Care (SKSC) providers, HRSN (Health Related Social Needs) providers, primary care providers, specialists, facilities, community health centers, ancillary providers, and labs.  Works closely with the Sr. Provider Relations Consultants and the Provider Relations Manager to identify issues and report trends. 

Acts as the primary liaison between the providers and internal WellSense departments including Provider Enrollment, Member Enrollment, Member & Provider Services, Claims, Audit, Marketing, Utilization Management and Care Management.

 

Our Investment in You:

·       Full-time remote work

·       Competitive salaries

·       Excellent benefits

Key Functions/Responsibilities:

·       Develops and enhances relationships with assigned providers including ACO’s, HRSN’s, primary care providers, specialists, community health centers and hospital systems through effective business interactions and outreach.

·       Works collaboratively with Provider Relations Consultant team members and Manager to develop and update provider orientation programs

·       Coaches and assists in the training of Provider Relations Consultants and Provider Relations Specialists.

·       Organizes, prepares and conducts orientations of network providers (administrative and clinical) and their staff. Takes the lead on specific WellSense initiatives as they relate to provider education. 

·       Develops provider presentations that clearly communicate plan information and updates. Delivers presentations to provider groups, health systems, and provider forums.

·       Provides guidance and support on plan products and policies to providers and coordinates office and provider site meetings.

·       Meets with assigned providers regularly according to site visit servicing standards.  Documents all pertinent provider communications and meeting notes in customer relationship portal.

·       Acts as liaison for all reimbursement, credentialing, claims, portal procedures and issues of assigned providers.  Facilitates resolution of complex contractual and member and provider issues, collaborating with internal departments as necessary.

·       Works collaboratively with Contract Managers in implementing and administering contractual provisions of provider agreement to ensure contractual compliance.  Monitors contractual compliance on an on-going basis.

·       Assists in the implementation of new provider contracts as needed so providers can be credentialed, loaded in systems timely and correctly, and notified within standards set by department. 

·       Manages flow of information to and from provider offices. Ensures active provider contacts are kept up to date for effective mailing and communication. 

·       Outreaches to providers to support WellSense initiatives, assigned projects and/or member grievances.

·       Analyzes operational issues related to territory and provider operations and includes other internal departments as necessary.

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

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

·       Represents Provider Engagement and WellSense at external provider and community events to maintain visible presence

·       Produces reports as needed to support provider education, servicing, credentialing and provider network maintenance.

·       Ensures quality and compliance with state Medicaid regulations and NCQA requirements. 

·       Other responsibilities as assigned.

·       Regular and reliable attendance is required.

Supervision Exercised:

·       Does not directly supervise staff. May provide technical supervision and support to less experienced staff as needed.

 

Supervision Received:

·       Indirect supervision is received weekly.

 

Qualifications:

 

Education:

·       Bachelor’s degree in business administration or a related field or an equivalent combination of education, training and provider relations or network management experience is required.

 

Experience:

·       4 or more years of progressively responsible experience in provider relations or network management required. 

 

Preferred/Desirable:

·       Experience in the Medicare provider healthcare insurance industry

 

Certification or Conditions of Employment:

·       Successful completion of pre-employment background check

Competencies, Skills, and Attributes: 

·       Knowledge or familiarity with Medicaid and Medicare is a plus

·       Understanding the provider community

·       Proven demonstration of effective communication skills (verbal and written), and interpersonal skills

·       Demonstrated ability to establish, build and maintain relationships with internal and external constituents

·       Strong analytical, research and organizational skills

·       Strong follow up skills a must

·       Ability to think and react quickly to address questions and issues while interacting with the provider community