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 Quality Specialist performs a critical function within Health Plan Operations. This role is responsible for validating employee outputs in various areas, including; Claims, Customer Care, and Enrollment, to ensure quality, accuracy, and regulatory compliance. In addition, the Quality Specialist collaborates with business partners across Operations and external vendors to create and maintain quality policies and processes to ensure the program meets the agreed-upon standards.

Our Investment in You:

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

Key Essential Functions/Responsibilities:

• Evaluate department outputs for accuracy and compliance with processing guidelines and departmental standards to validate process and workflow effectiveness and efficiency
• Perform quality audits on Membership eligibility and enrollment entry for accuracy and timeliness following regulatory standards and regulatory agencies
• Prepares and maintains Quality policies and procedures
• Conducts research, compiles and analyzes performance reports to identify the root cause of problems and recommend process improvements
• Participates with stakeholders to develop potential preventive and corrective actions
• Monitor external vendor quality, investigate discrepancies and report errors to the appropriate operation team
• Conduct accurate and timely quality reviews of claim adjudication activities, including appropriate adjudication decisions, and claim payment accuracy in compliance with adjudication policies and procedures, job aids, and guidelines
• Assist in the appeal process by providing supporting documentation and reference tools cited in the determinations and audit findings
• Tracks daily evaluation completion of assigned processing task/function and provides any noticeable performance trend data to the appropriate management team or Business Owner
• Coaches and provides ongoing feedback to staff based on trends and Quality findings
• Conducts one-on-one coaching as determined by management for performance improvement
• Assists with calibration sessions following department standards to help ensure consistency and validation of audit parameters, KPIs, and requirements
• Provides suggestions on new process documentation and materials to support quality initiatives and to improve overall performance and compliance across the Operations teams
• Provides feedback to department team leaders and managers
• Identifies and documents defects, inconsistencies, and potential risks in workflow process and documentation
• Maintains a comprehensive understanding of appropriate departmental policies and procedures and audit specifications

Qualifications:

Education Required:

• A Bachelor's degree in Business Administration, Education, a related field, or an equivalent combination of education, training, and experience is required

Required Experience:

• A minimum of 1-3 years of Quality Control, Quality Assurance, and Auditing
• 1-3 years of exposure in various departments in a health insurance organization, such as; customer service and enrollment, claims and premium billing experience, or equivalent experience, is required
• Working knowledge of Managed Care Operations, including a basic understanding of Claims, Enrollment, and Customer Service functions with the application of Quality Improvement concepts, practices, and procedures, is required

Preferred/Desirable:

• Previous health insurance work experience
• Experience in working with Witness or other call-monitoring software
• Previous call center quality assurance experience preferred

Competencies, Skills, and Attributes:

• Strong interpersonal communication and relational skills
• Must be able to work collaboratively and cooperatively as a team member
• Ability to synthesize and process complex information and deliver the news verbally and in writing in a clear, concise, and articulate manner
• Highly organized, detail-oriented, self-directed, and able to work independently and in team settings
• Demonstrated competency with MS Office and MS Windows, specifically in Microsoft Excel
• Excellent analytical, oral, verbal, and written communication and customer service skills
• Must be able to multi-task, prioritize projects and work well with deadlines
• Must be flexible and willing to perform all necessary and appropriate duties to attain departmental and organizational goals

Working Conditions and Physical Effort:

• Regular and reliable attendance is an essential function of the position
• Ability to work OT during peak periods
• Requires the ability to balance multiple priorities and function in a complex, rapidly changing environment

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