We are offering a guaranteed $5,000 sign on bonus for any person who is hired for this role!

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.

As a WellSense Provider Relations Consultant, you’ll act as the primary liaison between WellSense’s contracted medical providers and internal WellSense departments, such as Claims, Benefits, Audit, Member and Provider Enrollment and Clinical Services.

In this role, you’ll identify and resolve multiple issues and work closely with the leadership team to problem-solve and report trends.

Our Investment in You :

• Competitive Salaries
• Excellent Benefits

Position requires up to 50% local travel to our provider partners within the assigned region. Position will work from home when not traveling

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 WellSense 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, including facilitating the resolution of complex contractual and member / provider issues while collaborating with internal departments as necessary
• Provide general education and support on WellSense products, policies, procedures and operational issues as needed
• Manage the flow of information between internal departments and providers to ensure timely communication full understanding regarding WellSense changes and updates
• May outreach to providers according to WellSense initiatives
• Facilitate interdepartmental collaboration to resolve complex provider issues
• Identify system updates as needed and complete research related to provider data in Onyx and Facets
• Process reports as needed to support provider education, servicing, credentialing and recruitment
• Ensure quality and compliance with state agencies and NCQA
• Other responsibilities as assigned
• Ability to understanding of and implement relevant WellSense policies and procedures
• Regular and reliable attendance is an essential function of the position

Qualifications : Education :

Education :

Bachelor’s degree in business administration or a related field or an equivalent combination of education, training and experience is required

Experience :

• Two 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

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 in a team environment, prioritize and manage multiple tasks, be flexible, and work independently
• Excellent organizational skills
• Proven expertise utilizing Microsoft Office products
• Effective communication skills (verbal and written)
• Strong follow-up skills

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.

Required Skills

Required Experience

Last updated : 2024-05-01