Reviews cases referred by the prior authorization non clinical staff according to member benefits, provider availability, and pre determined medical necessity criteria Clearly and succinctly presents cases to ensure quality care while advocating for appropriate utilization of health system resources (e.g. site of service, level of care, length of stay, etc) consistent wit

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

The Staff Accountant is a key member of the Accounting team and works closely with all members of the team in meeting close deadlines, working with various general ledger modules, preparing account reconciliations, and supporting internal and external audits. Positive and team oriented work ethic is critical to this role.

This position is responsible for accurate and timely research of all claim dispute inquiries, timely processing of adjustments and acts as a claims liaison between internal and external partners and helping with other Claims related initiatives. Responsible for the accurate and timely processing of internal inquiries to the Claims Resolution team. Must complete duties wit

Designs, implements, and manages the Business Continuity Program for the health plan Collaborates with department directors and the executive team to develop and implement plans to anticipate, address, and mitigate the effects of various business interruptions Develops, updates and executes business continuity program goals, including development and reporting against met

Reporting to the Director of Contracting, the Operations Manager leads and oversees the reports, audits and other issues concerning all provider contracts, including any pertinent changes and modifications applicable to these contracts. Establishes and monitors Key Performance Indicators. Accountable for quarterly provider directory management, online provider directory i

The WellSense Health Plan Manager of Hospital and Physician Contracts is responsible for the development, implementation and management of a cost effective provider network, maintaining complex and geographically diverse contracts. The Manager leads a team of Hospital and Physician Contract Managers and is responsible for the development of network wide ancillary strategi

The Manager of Healthcare Analytics is responsible for financial analysis, measurement, and contract compliance as it relates to WellSense's Clinical Vendors. Working closely with Finance leadership, clinical leadership, and leaders from WellSense's Clinical Vendors, the Manager will ensure the financial integrity of these partnerships by leading the development and commu

The WellSense Plan Manager of Ancillary Contracts is responsible for the development, implementation and management of a cost effective provider network, maintaining complex and geographically diverse contracts. Serves as mentor and manage o Ancillary Contract Managers, leading in the development of network wide ancillary strategies to improve efficiencies and access. Und

The Clinical Care Manager provides holistic medical care management services for members throughout the continuum of care by assessing the member clinically as well as member's readiness to make behavioral changes and actively participate in a care plan, establish goals and meet those goals. Well Sense Health Plan members may include those who have chronic conditions and

Provide short and long term forecasts for various contact centers and departments Including inbound and outbound calls, emails, faxes, chats, written correspondence, claims, enrollment files, caseloads, and other volume based measures Maintenance of current and long term staffing requirements needed to meet service level objectives and other key performance indicators Sup

Position Health Data Analyst III (2 positions available) Location Charlestown (Boston), MA. Report to main office in Charlestown, MA. Eligible to work remotely from anywhere in the U.S. but must work from a state the employer is legally eligible to employ Alabama, Arizona, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Indiana, Kansas, Kentucky, Maine, Maryland

Under the direction of the Vice President of the Senior Vice President of Behavioral Health, the Senior Director of BH Clinical Programs oversees the BH Care Management, BH Utilization Management and Clinical Programming teams. The Senior Director develops and integrates the strategies to enhancing the quality of care for patients, satisfaction, healthcare outcomes in a c

Reporting to the Vice President of Network Strategy, the Director of Behavioral Health Network Strategy is responsible for contract strategy and execution for WellSense Health Plan's behavioral health (BH) network for Medicare, Medicaid and Commercial products across multiple states. The Director of BH Network Strategy will be a thought leader and central point of contact

The Operations Trainer role is pivotal in elevating new and existing employee's performance and capabilities through classroom and virtual training sessions. The role primarily supports Health Plan Operations departments such as Member and Provider Service, Claims, Member Enrollment, and Provider Appeals. The Operations Trainer will also conduct job specific training, inc