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Senior Provider Relations Consultant, BH Network Strategy

WellSense Health Plan is a nonprofit health insurance company serving members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances.

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 Senior Provider Relations Consultant (Snr PRC) is responsible for managing an assigned territory of professional and facility behavioral health providers to enhance their relationships with WellSense Health Plan across Medicare, Medicaid and Commercial products. The Snr PRC serves as primary liaison between WellSense and key behavioral health providers, leading provider onboarding and health plan collaboration. The Snr PRC will be actively involved in training and development of PRCs and internal workflows. The Snr PRC manages their assigned territory inclusive of multiple behavioral health and substance use disorder provider types. The Snr PRC acts as liaison between behavioral health provider network and key internal health plan departments and works 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:

+ **Develop and enhance our physician, clinician, community health center and hospital relationships through effective business interactions and outreach**

+ **Initiates and facilitates resolution of complex contractual and member/provider issues through collaboration with internal departments**

+ **Coaches and assists in the training of Provider Relations Consultants**

+ **Assists with the development of training materials**

+ **Works collaboratively with the Manager of Behavioral Health Network Strategy to develop and update provider orientation programs**

+ **Organizes, prepares and conducts orientations of network providers (administrative and clinical) and their staff**

+ **Ensures quality and compliance with state Medicaid/Medicare regulations and NCQA requirements**

+ **Conducts analysis of operational issues in the context of impact to territory of providers**

+ **Acts as liaison to behavioral health trade organizations as needed**

+ **Leads provider education for health plan initiatives and manages the flow of information to and from provider offices**

+ **Provides instruction and support on health plan products and policies**

+ **Coordinates office and provider site clinical and administrative meetings; meets with assigned providers regularly according to pre-set site visit servicing standards**

+ **Acts as liaison for all reimbursement, credentialing, claims, EDI web site procedures and issues of key providers**

+ **Partners with Contract Managers to implement contractual provisions to ensure contractual compliance**

+ **Facilitates timely problem resolution**

+ **Monitors and communicates market trends and issues**

+ **Identifies system updates needed and completes research related to provider data in Onyx and Facets**

+ **Represents Provider Relations and the plan at external provider and community events**

+ **Process reports as needed to support provider education, servicing, credentialing and recruitment**

+ **Other responsibilities as assigned**

Supervision Received:

+ **Weekly supervision from Manager of Behavioral Health Network Strategy**

Qualifications:

Education:

+ **Bachelor’s degree in Business Administration, related field or an equivalent combination of education, training and experience**

Experience:

+ **4 or more years of progressively responsible experience in a managed care or healthcare environment. Experience with Behavioral Health providers preferred**

+ Experience with Commercial, Medicare and Medicaid reimbursement methodologies

+ Understanding of provider coding and billing practices for behavioral health services

+ Strong ability to navigate complex matrix environment

Certification or Conditions of Employment:

+ Pre-employment background check

Competencies, Skills, and Attributes:

+ **Knowledge of and experience with ICD-10, CPT/HCPCS Codes, and billing claim forms**

+ **Understanding of Massachusetts and New Hampshire provider community**

+ **Demonstrate initiative, judgment, discretion and ability to operate within politically sensitive framework**

+ **Strong analytical and organizational skills**

+ **Ability to quickly solution to address issues while interacting with the provider community**

+ **Proven expertise utilizing Microsoft Office suite of products.**

+ **Effective communication skills (verbal and written)**

+ **Ability to set and manage priorities**

Working Conditions and Physical Effort:

+ **PRCs work out of a remote home office environment with the possibility of some travel to provider offices**

+ **Ability to work in a fast-paced environment**

+ No or very little physical effort is 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. 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

Important info on employment offer scams:

According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not solicit individuals via text, we do not ask or require downloads of any applications, or “apps,” and applicant screenings, interviews and job offers are not conducted over text messages or social media platforms. You should never pay money for the promise of priority, interview or employment. We do not ask individuals to purchase equipment for, or prior to employment. To avoid becoming a victim of an employment offer scam, please followthese tips from the FTC (https://consumer.ftc.gov/consumer-alerts/2023/01/looking-job-scammers-might-be-looking-you?utm\_source=govdelivery) _._