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 Enrollment Team Leader is responsible for assigning work based on department goals. Provides recommendations on department policies and work processes. Implements programs to assure operational efficiency within the Department as well as to meet the Plan goal to improve the overall provider experience. Applies in-depth functional knowledge to achieve focused business goals; needs to remain current in the technical aspects of provider enrollment. Implements defined cross-functional procedures and programs. Implements short term solutions to allow the organization to operate at peak performance. Assures the accuracy of newly loaded data for existing and new providers into Onyx, and for accuracy of changes due to implementation of data clean up projects related to payment and compliance.

Our Investment in You:

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

Key Functions/Responsibilities:

• Documents and maintains an electronic library of all Provider Enrollment processes and job aids
• Coordinates the day to day activities of the Provider Enrollment staff, assuring timely inventory management. Assigns staff daily to meet department turnaround time goals
• Responsible for implementing steps needed to assure compliance with cross departmental processes to meet contractual and NCQA compliance, including but not limited to practitioner terminations and loading of new providers for new contracts. Participates in report generation to assure adherence to compliance across the organization
• Works with Provider Relations and Contracting staff to implement new contracts. Oversees data entry accuracy of large scale contract changes
• Identifies and implements Department data clean up efforts related to provider payment issues, and presentation in the Provider Directory. Communicates findings to Provider Relations, Contracting, Finance/analytical staff. Oversees corrections to the data
• Oversees entry of provider related data into Onyx and ensures integrity of data. Participates in cross-functional workgroups as requested in order to promote provider data integrity
• Develops, sends, tracks, resolves complex IT ticket requests to assure proper payment assignment
• Implements all aspects of provider enrollment to ensure provider hierarchy and data are loaded appropriately in all relevant systems. This includes understanding and communicating unique arrangements and ensuring the Plan accurately enrolls the providers with those arrangements
• Develops, manages and utilizes a standard set of reports for Provider Enrollment Specialists to use to manage records in the enrollment process in order to meet turnaround time goals
• Oversees entry of provider related data into Onyx and participates in cross functional workgroups as requested in order to promote integrity of data
• Retrieves, compiles, reviews, and ensures accuracy of provider data from relevant sources and researches and corrects discrepancies. Recommends and implements business rule changes
• Responsible for developing, implementing and reporting on the results of the data audit function for the Department. Reports to internal and external audiences in compliance with the Model Audit Rule
• Provides support to Plan staff as the subject matter expert of business rules and set-up of network systems including Onyx and Facets. Trains Plan staff as needed on Onyx
• Analyzes and proposes solutions on provider data issues as required
• Covers for Manager in their absence as needed
• Other duties as assigned by Manager
• Regular and reliable attendance is an essential function of this position

Qualifications:

Education Requirements:

• Bachelor’s degree in Business Administration or related field or equivalent combination of training and experience

Experience Requirements:

• 2 + years business experience in a managed care or healthcare setting
• 3 + years of progressively responsible Provider Relations and/or Provider Enrollment experience

Competencies, Skills, and Attributes:

• Demonstrated competence using Microsoft Office products especially Excel and Access; familiarity with FACETS and/or Onyx preferred
• Proven demonstration of effective communication skills (verbal and written), and interpersonal skills to lead and direct the efforts of others, both internally and externally
• Ability to be flexible and work independently. Ability to manage multiple tasks and possess excellent organizational skills

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 440,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.

• WellSense will require proof of COVID-19 vaccination(s) as a term of employment for all employees. The company may make exceptions to this requirement in certain limited circumstances for religious or medical purposes.