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 Manager of Behavioral Health Payment Strategy will lead policy development and performance initiatives to align with the organization's corporate strategy and contractual/compliance requirements posed by regulatory oversight agencies, including CMS, MassHealth, NH Medicaid, and the DOI. This individual will ensure payment policy and payment system compliance and accuracy through the development of KPIs, SLAs, and SOPs. This individual will work collaboratively with other departments to ensure payment alignment between policies, systems, and encounter data.

Our Investment in You:

*Full-time remote work

*Competitive salaries

*Excellent benefits

Key Functions/Responsibilities:

• Leads and coordinates the activities of Behavioral Health payment policy development, and collaboration efforts with other departments to ensure consistency with all Plan policies and applicable regulations through the Payment Policy Committee.
• Develops policy strategies to drive cost savings initiatives, operational efficiency, and completeness of encounter data.
• Leads, executes, and monitors the organization's corporate strategy with respect to Behavioral Health payment systems.
• Develops and monitors maintenance and enhancement efforts for payment processing, driving accurate and efficient claims payment.
• Ensures consistency between Plan policies, system payment rules, and encounter data.
• Develops and manages KPIs and reporting dashboards for evaluating policy metrics and payment integrity associated cost savings.
• Ensures payment policy compliance and monitors regulations and industry policy changes from HIPAA, Medicare & Medicaid, Official Coding & Reporting Guidelines, and Industry coding standards.
• Provides leadership and guidance to staff responsible for the timely escalation of problems associated with payment policies, collaborate with other teams to determine appropriate solutions, and timelines for closure.
• Identifies and implements process improvements to increase transaction accuracy, or improve overall performance within the department.
• Maintains comprehensive understanding of and adherence to relevant policies, procedures, and regulations while staying abreast of changes and/or updates in regulations or competitive market space.
• Manages multiple concurrent priorities, interacting with other departments, team members, and participates in, and leads interdepartmental teams.
• Strives to develop a team of individuals with a common goal of achieving WellSense goals and alignment with corporate strategies.
• Other duties as assigned

Supervision Exercised:

• Manages 3-7 staff directly.

Supervision Received:

• General supervision is received weekly.

Qualifications

Education Required:

• Bachelor's Degree in a related field or the equivalent combination of training and experience.

Education Preferred:

• AHIMA or other nationally recognized coding certification

Experience Required:

• 10 or more years direct work in claims processing, payment policy, billing, or contracting.
• 5 or more years experience working with Medicare, Medicaid or commercial Behavioral Health billing, coding, or payment rules and regulatory requirements.
• Extensive background of institutional or professional coding principles.
• Extensive experience working with industry standard methods of payment including DRG, APC, APG, etc.
• Experience working with industry standard payment systems and claim processing; such as Facets or Optum pricing software.

Experience Preferred/Desirable:

• 2 or more years' experience in supervisory position
• Optum Claim Editing System (CES), Data Driven Rules
• Optum Prospective Payment Systems
• Cognizant Facets claim adjudication system
• Experience with HIPAA transaction and 837 standards

Required Licensure, Certification or Conditions of Employment:

• Successful completion of pre-employment background check

Competencies, Skills, and Attributes:

• Effective collaborative and proven process improvement skills.
• Strong oral and written communication skills; ability to interact within all levels of the organization.
• A strong working knowledge of Microsoft Office products.
• Demonstrated ability to successfully plan, organize and manage projects.
• Excellent analytic and problem solving skills and ability to manage multiple projects and priorities.
• Ability to meet deadlines, multi-task and problem solve.
• Ability to negotiate enterprise solutions with other departments that work interdepartmentally.

Working Conditions and Physical Effort:

• Regular and reliable attendance is an essential function of the position.
• Work is normally performed in a typical interior/office work environment.
• No or very limited physical effort required. No or very limited exposure to physical risk.

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.