Payment Integrity Operations Manager

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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

Reporting to Director of Provider Audit, Other Party Liability and Special Investigations, the Payment Integrity Operations Manager is responsible for providing operational oversight of provider audits programs including compliance, program development, evaluation, and performance monitoring. This role assumes management of and accountability for day to day Payment Integrity operations and is the subject matter expert for Payment Integrity operations.

Our Investment In You

• Full-time remote work
• Competitive salaries
• Excellent benefits
  
  

Key Functions/Responsibilities

• Work with Director on development and execution of Payment Integrity strategy
• Identify trends, risks and opportunities to set strategic direction for Payment Integrity
• Collaborate with functional leaders to identify execute initiatives that support strategic and operational objectives as related to payment integrity
• Monitor performance of Payment Integrity external vendor and lead the implementation of vendor performance reporting and oversight
• Produce provider scorecards related to Payment Integrity initiatives and lead provider meetings to review results and trends
• Synthesize information into impactful materials and presentations to facilitate recommendations to the COO and Executive Teams
• Effectively work in a matrix environment to accomplish work across multiple teams in the health plan and health system
• Understand and visualize data, make data driven decisions and create reporting
• Develop, implement, and enhance processes to drive overall performance of Payment Integrity initiatives
• Lead implementation projects assigned in accordance of priority
• Develop methodologies and infrastructure to measure the impact of executed initiatives
• Represent Provider Audit as the subject matter expert on corporate initiatives
• Makes recommendations related to Payment Integrity impact and operations
• Leads implementation of any resulting work, internal project teams, coordinates communication, training, documentation and reporting
• Identifies, communicates, and escalates issues to the Director of Provider Audit, OPL and SIU on a timely basis
• Independently problem solves programmatic issues and implements appropriate solutions
• Responsible for ensuring compliance with contractual and regulatory requirements and for effectively documenting the components of the programs necessary for compliance with regulatory standards and submission to external agencies
• Develops and oversees the production of regulatory reports and standard KPI reports to monitor and report on overall department metrics and program evaluation
  

Qualifications

Education:

• Bachelor’s degree
• Master’s degree in Business Administration or related field preferred
  
  

Experience

• 5+ years of healthcare/managed care experience required
• 5+ years of claims Payment Integrity experience
• Facets experience preferred
• Project management experience preferred
  
  

Certification Or Conditions Of Employment

• CPC or CCS certification preferred
• Project management certification preferred
  
  

Competencies, Skills, And Attributes

• Strategic thinker
• Exceptional written and oral communication skills
• Excellent organizational skills and attention to detail
• Ability to interact with all levels of the organization, as well as external stakeholders
• Superior meeting facilitation skills and experience in leading cross-functional teams
• Demonstrated ability to work independently and manage multiple complex projects simultaneously
• Proactive, motivated, and a collaborative team player
• Demonstrated ability to adapt quickly to changing priorities
• Ability to analyze, compile, format, and present data to a variety of stakeholders
• Strong critical thinking, analytical, and problem-solving skills
• Proficiency with MS tools including Word, Excel, PowerPoint, Visio and MS Project
• Demonstrated ability of managing competing priorities as well as stakeholders with differing objectives/perspectives
• Effective at forming alliances with other departments to develop partnerships and commitment toward completing the project
• Able to negotiate enterprise solutions with other departments that work interdepartmentally
  
  

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

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