Provider Relations Consultant NH in Manchester

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:

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 policies & 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 50%.

Compensation Range:

$57,500- $83,500. This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.

Note: This range is based on Boston-area data, and is subject to modification based on geographic location.

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.