Develops and enhances our physician, clinician, community health center and hospital relationships through effective business interactions and outreach Works collaboratively with Provider Relations Consultants and Supervisor to develop and update provider orientation programs Coaches and assists in the training of Provider Relations Consultants and Provider Relations Spec

The OCA Training Coordinator is responsible for developing and maintaining training infrastructure for the Office of Clinical Affairs. Reporting to the Manager of OCA Operations, the OCA Training Coordinator will work with clinical trainers and other stakeholders across the Office of Clinical Affairs to support the day to day functions and operations when it comes to adul

Assists our provider partners in the interpretation of data tools and analytics provided by the Plan, including Alternative Payment Arrangements (APMs) and Quality Incentive Programs (QIPs) reporting and other incentive programs developed. Ensures the contracting and implementation process is administered appropriately and ensures integrity of data. Ensures materials used

Prioritizes and processes incoming requests, including authorizing specified inpatient admissions requests, as outlined in departmental policies, procedures, and workflow guidelines Requests clinical information and discharge dates per workflow Refers requests that require clinical judgment to Inpatient Utilization Clinician Meets or exceeds position metrics and turnaroun

Develops, maintains and manages all plan fee schedules and code pricing. Monitors multi state regulations including DHHS, EOHHS, and CMS websites, listservs and other sources to identify existing payment practice and proposed changes. Determine the scope and impact of the change on Plan operations and seek to implement changes as necessary. Business owner in managing soft

Manages a panel of high risk, medically complex members Completes timely initial and on going face to face comprehensive assessments with Member to evaluate Member's medical, behavioral health, functional status, and socioeconomic needs Administers MDS HC assessments and other required assessment tools Facilitates meetings of the PCT and serves as clinical subject matter

Execute assigned projects to deliver project benefits Effectively work across multiple business units and functional teams to drive results Create long and short term plans, including setting targets for milestones and adhering to deadlines Make effective decisions when presented with multiple options for how to progress with assigned projects Communicate with executives

Responsible for the coordinated management of multiple large scale, critical or complex projects. The Senior IT Project Manager (PM) is responsible for overseeing all aspects of project work to ensure that goals and objectives are accomplished within the constraints of the budget, schedule, and stakeholder expectations. Monitors progress according to plan, identifying and

Initiates the collection of all pertinent information/documentation from Providers and their office staff. Verifies credentials through the appropriate primary sources. Independently reviews credentialing files to ensure completion and accuracy of information, per Plan's policies. Ensures all files are completed in a timely manner, and meet the appropriate turnaround requ

WellSense Health Plan is seeking a dedicated and experienced Senior Health Data Analyst to join our team on a full time, regular basis. The Senior Health Data Analyst is a key member of the team and serves as a strategic partner to various functional areas throughout the organization to meet corporate objectives. Under the leadership and guidance of Senior Director of Cli

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

The Project Coordinator (PC) will work closely with Project and Program Managers to ensure the success of strategic initiatives at WellSense. PCs assist with the preparation and maintenance of key project & program artifacts, such as charters, project plans, schedules, budgets, timelines, and status reports. They also assist with administrative duties related to project e

Responsible for accurate and timely implementations of pharmacy benefits and operations configurations Provides project management support for all pharmacy services initiatives across all lines of business Responsible for initiation, planning, tracking, documenting, execution, and monitoring and controlling of program implementations Proactively works with the project tea

Develops and maintains corporate payment policies, and works collaboratively with the Clinical Editing Manager to ensure consistency with the Plan's adjudication system(s) Monitors DHHS, EOHHS, and CMS websites, listservs and other sources to identify existing payment practice and upcoming changes Determine the scope and impact of the change on Plan operations and seek to

The Operations Reporting and Performance Analyst (ORPA) plays an essential role in improving organizational effectiveness by analyzing operational data and identifying opportunities for learning and development. The OPRA collects and analyzes data to assess performance metrics, identifies training needs, and implements strategies to improve employee performance and skill