WellSense Health Plan

The Strategist leads high-level quality performance activities to meet regulatory, accreditation, and contractual requirements, overseeing the planning, execution, and monitoring of projects impacting quality outcomes like HEDIS performance. This role involves partnering with internal teams and vendors to ensure successful project delivery, data issue resolution, and alignment with organizational quality goals.

The Prior Authorization Clinician reviews proposed hospitalization, home care, and inpatient/outpatient services for medical necessity and efficiency to ensure members receive appropriate and timely care. Key functions include determining medical appropriateness using guidelines, performing utilization reviews, and communicating outcomes to providers and members.

The specialist performs outreach calls to members with quality gaps in care, providing education, motivational support, and scheduling assistance to close these gaps and improve quality outcomes. This role also involves documenting activities, tracking progress, evaluating Health Related Social Needs, and collaborating internally to ensure coordinated member support.

The Staff Accountant will manage the Plan’s accounting and financial systems, including preparing financial and statistical reports and ensuring compliance with regulatory and contractual commitments across all lines of business. Key monthly tasks involve preparing journal entries, analyzing and reconciling general ledger accounts, handling medical claims check runs, and managing fixed asset reporting.

The Business Encounter Data Analyst compiles and analyzes encounter data, ensuring claims data is complete, accurate, and timely to meet CMS and State Service Level Agreements (SLAs). This role involves reviewing encounter rejections, resolving data/system issues, and developing supporting business processes and workflows.

The Claims Quality Inspector is responsible for the thorough and accurate review of adjudicated claims and Enrollment entry against established corporate guidelines and protocols. Key functions include conducting accurate and timely quality reviews of claim adjudication activities and performing quality audits on Membership eligibility and enrollment entry.

The Coder manages daily responsibilities including chart abstraction, vendor auditing, and reporting, ensuring claims accurately reflect diagnosis information from medical records according to regulations. Responsibilities involve performing code abstraction and quality audits to ensure accurate ICD-10-CM code assignment supported by clinical documentation.

The Clinical Care Manager provides holistic medical care management by assessing members, establishing goals, and developing Individual Care Plans emphasizing self-management and coordination across the continuum of care. Key functions include conducting targeted assessments, utilizing motivational interviewing, coordinating resources to address social determinants of health, and monitoring outcomes to improve health and decrease costs.

The primary function of this role is to lead a team of Member Services and Provider Services supervisors and their support staff. The ideal candidate will demonstrate strong leadership, effective coaching abilities, excellent customer service instincts, and a genuine desire to su...

Reporting to the Director of Member and Provider Service, the Operations Manager is responsible for providing operational oversight including compliance, program development, evaluation, and performance monitoring. This role assumes management of and accountability for day-to-day...