Manages a panel of high risk, medically complex members Completes timely initial and on going face to face comprehensive assessments with Member to evaluate Member's medical, behavioral health, functional status, and socioeconomic needs Administers MDS HC assessments and other required assessment tools Facilitates meetings of the PCT and serves as clinical subject matter

Generates and/or distributes member documents and files Data entry of confidential member information into multiple databases Generates simple reports for care management team Initiates and follows up on requests for provider information Assists in scheduling Primary Care Team meetings and exchanging information, facilitating communication among team members as needed Ass

Monitors actual FCR and NPS performance against corporate targets; presents findings; proactively investigates and communicates explanations for variation and conducts root cause analysis. Provides critical data analysis and recommendations to establish corporate goals related to FCR and NPS. Conducts deep analysis on data related to FCR and NPS, reviews member surveys, l

Receive, process, and review all prior authorization requests received through fax, phone, or electronic prior authorization systems in accordance with all regulatory and accreditation requirements Properly apply clinical policy criteria to the review of prior authorization requests Review and interpret member's eligibility, claim history, and Pharmacy Program information

The Manager of Risk Adjustment and Trend Analytics is a key member of the Finance management team. Under supervision of the V.P of Financial Planning and Performance Analysis, the Manager oversees risk adjustment analysis primarily related to the MassHealth Medicaid and New Hampshire Medicaid lines of business, directly impacting and improving the revenue for these produc

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

Reporting to the Manager of Consumer Sales and Performance, the Broker Account Executive is a licensed sales professional with experience in Medicare/Medicare Advantage and individual ACA markets and is responsible for building and managing relationships with WellSense's contracted brokers. The Broker Account Executive provides strategy support and product training broker

The Licensed Behavioral Health Clinician provides care management services at facilities, in the community and telephonically for WellSense members receiving behavioral health (BH) and substance use services. The Licensed Behavioral Health Clinician works alongside medical Utilization Management and medical Care Management staff, pharmacists, and medical directors as part

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

WellSense Health Plan is seeking a dedicated and experienced Senior Health Data Analyst to join our team on a full time, regular basis. The Senior Health Data Analyst is a key member of the team and serves as a strategic partner to various functional areas throughout the organization to meet corporate objectives. Under the leadership and guidance of Senior Director of Cli

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 Executive Assistant role provides comprehensive administrative support to the WellSense President and executive team in managing daily business operations, communications and coordination both internally and externally. We seek a collaborative team player who is proactive, detail oriented, and highly accountable. A high degree of professionalism is essential, as this

At the direction of the Manager of Behavioral Health Operations, the Behavioral Health (BH) Program Manager, New Hampshire (NH) is responsible for leading and resolving high visibility behavioral health (BH) initiatives, issues and priorities through significant interface with the health plan's material subcontractor. Key deliverables include the oversight of New Hampshir

Responsible for the coordinated management of multiple large scale, critical or complex projects. The Senior IT Project Manager (PM) is responsible for overseeing all aspects of project work to ensure that goals and objectives are accomplished within the constraints of the budget, schedule, and stakeholder expectations. Monitors progress according to plan, identifying and

Investigate, document, track and assist with claims resolution Interact with various operational departments to assure accurate and timely payment of claims in accordance with WellSense policies and procedures Identify system changes impacting claims processing and work internally on resolution Identify systematic issues and trends and research for potential configuration