Designs, implements and leads the Plan's continuous quality improvement infrastructure. Acts as an internal consultant and resource to all levels of the organization relative to CQI processes and standards. Keeps abreast of strategic operating priorities and corporate goals to ensure processes, plans and policies are designed to fulfill strategic objectives. Additionally

Reporting to the Director of Operations, Utilization Management, the Medical Management Program Analyst (MMPA) plays a key role in the implementation of new medical management systems, the evaluation of medical management activities and business processes and the development of a best in class utilization management (UM) program. The MMPA coordinates data management activ

The Product Benefit Administration Specialist is responsible for day to day benefit/product administration operations, ensuring the alignment of business processes and decisions with the benefit/product strategy as well as ensuring compliance from a benefit perspective including the development and management of Evidence of Coverage (EOC), Product Contract Documents, Memb

Directs financial planning and associated analysis activities at a leading health plan with a large market share of Medicaid lives in Massachusetts and New Hampshire, as well as Commercial and Medicare lines of business. Overseeing a team of 4 6, this key finance leader is responsible for consolidating the annual financial budget and quarterly reforecast projections acros

The Operations Trainer develops a wide variety of training programs and materials to support the Claims, Call Center, and Enrollment teams. The trainer researches, develops, and facilitates in house training courses for new and existing employees. Develops training competency tools that will ensure the quality, consistency and timeliness of department activities. Maintain

The Utilization Management (UM) Special Projects Manager is responsible for efficiently managing major department projects and programs with cross functional impact and significant complexity, risk and/or cost for all product lines (e.g. Medicaid, Medicare Advantage, Medicare Dual Eligible Special Needs & ACA) for the Utilization Management department. Responsibilities in

Reporting to the SVP Network Management & Operations, the Senior Director, Network Operations Strategy is responsible for the development of the enterprise Network Operations Strategy function with a focus on optimizing overall performance, total value and the tools and processes used to manage the network. This senior leader will be accountable for implementing a network

The Program Coordinator works with relevant stakeholders to support the administration of the Special Kids Special Care program. The individual is responsible for working with the SKSC clinical team and serves as the primary liaison to various key WellSense departments including Member Services, Public Partnerships, Utilization Management, Vendor Management, Enrollment an

The Appeals and Grievance Specialist is responsible for managing the resolution process of medical and pharmacy member appeals and/or member generated complaints/grievances, and ensuring compliance with contractual obligations, regulatory requirements and accreditation standards. Our Investment in You Full time remote work Competitive salaries Excellent benefits Key Funct

The Manager of Application Services and Support leads a team in the delivery of technology support services to internal users of WellSense business applications. This includes WellSense custom built and purchased software applications extensions, interfaces, extracts, utilities, and web portals, as well as ownership and support of the enterprise job scheduling and manage

Develops and maintains organization Behavioral Health payment policies, and works collaboratively with the Payment Systems team to build system requirements to ensure consistency with adjudication systems. Develops and implements policy research and analysis strategies. Continually assesses and evaluates payment policy compliance with CMS, HIPAA, industry standards, plan

Utilizes motivational interviewing techniques, systems theory, change theory, acceptance and commitment approaches, patient activation and psycho education to engage members in care management Supports and enhances the member's capacity to self manage by detecting underlying mental/behavioral health issue impacting general health Establishes and maintains effective workin

Evaluates and approves requested services using organizational policies or InterQual screening criteria. Manages appropriate cases that require medical necessity review such as home care, elective inpatient and outpatient service requests. Monitors and complies with all state, federal and regulatory requirements relative to accuracy and turnaround times and adheres to the

T he Director of Utilization Management (UM) Operations i s ac c o u n t a b l e f or developing and maintaining the framework to achieve efficient and effective operational processes, policies and procedures to support the department's performance and quality metrics. This includes responsibility for robust performance measurement monitoring and reporting for both clinic

The Coder manages the day to day responsibilities of chart abstraction and reporting in accordance with state and federal regulations. The coder will abstract from inpatient and outpatient medical records and record findings via electronic data base and/or excel spread sheets. The coder ensures that all claims accurately reflect the appropriate diagnosis information as ou