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:

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 to including primary care providers, community health centers and hospital systems through effective business interactions and outreach.
• Collaborates with various WellSense departments to ensure accurate provider data and timely payment of claims, consistent with the plan's policies and procedures.
• Identifies system changes or trends impacting claims processing and payments and works internally on resolution.
• Produces reports as needed to support provider education, servicing, credentialing and network maintenance.  This includes Provider Demographic reports, Panel Reports, Claim Detail reports, etc.
• Assists in the development of provider presentations that clearly communicate plan information and updates. Delivers presentations to provider groups, health systems, and provider forums.
• Meets with assigned providers regularly according to site visit servicing standards.  Documents all pertinent provider communications and meeting notes in the customer relationship portal.
• Acts as liaison for all issues with provider to include, 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.
• Outreaches to providers to support WellSense initiatives and assigned projects.
• Supports providers on Member grievance questions and process.
• Provides education, training, and support on WellSense products, policies, procedures, web portal, and operational issues. 
• Manages timely responses to and from internal departments to ensure effective communication regarding updates.
• Identifies system issues and updates needed; completes research related to provider data in plan systems.
• Manages flow of information to and from provider offices. Ensures active provider contacts are collected and in the Plan’s system for effective mailing of plan notices and communication. 
• Ensures quality and compliance with State Agencies and NCQA. 
• Other responsibilities as assigned.
• Regular and reliable attendance is required.

Supervision Exercised:

·       None

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:

• 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:

• Successful completion of pre-employment background check.

Competencies, Skills, and Attributes:

• Experience with ICD-10, CPT/HCPCS Codes, and billing claim forms.
• Ability to work as a team member, manage multiple tasks, be flexible, work independently, be pro-active, think outside the box, and possess excellent organizational skills.
• Proven expertise utilizing Microsoft Office products.
• Effective communication skills (verbal and written).
• Strong follow-up skills a must.
• Proficient in multi-tasking.
• Ability to set and manage priorities and thrive in a fast-paced environment.

Working Conditions and Physical Effort: 

• Must be willing to travel to assigned providers for servicing to meet business needs up to 50% of time
• Must be able to travel to multiple provider offices across a wide geographic area on a regular basis, often within the same day.
• In office work performed in a typical remote home office 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