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Its 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 the Manager of Care Management Operations, the Operations Manager is responsible for providing operational oversight and analysis of our care management programs including compliance, program development, evaluation, and performance monitoring. This role assumes management of and accountability for the day to day non-clinical operations for these programs and is the subject matter expert for program operations.
Our Investment In You
Full-time remote work
Competitive salaries
Excellent benefits
Key Functions/Responsibilities
Responsible for ensuring compliance with contractual and regulatory requirements and for effectively documenting the components of the programs necessary for compliance with regulatory and accreditation standard and submission to external agencies.
Responsible for analyzing the impact of accreditation and regulatory changes and makes recommendations on programmatic changes to ensure compliance.
Directs and manages all non-clinical operational and management activities of the Care Management teams including the development and implementation of effective metrics to monitor productivity and compliance.
Facilitates operations team meetings and ad hoc departmental meetings.
Identifies opportunities to improve existing operational policies and procedures and develops new policies and procedures as necessary.
Provides direction to internal departments and CMs on decisions needed for members as it relates to benefits, payment of services, and any other non-clinical issues that are presented. Works with clinical departments on issues requiring clinical collaboration and coverage.
In collaboration with the Medical Management team, represents the programs and the Director in complex cross-functional teams and projects as the subject matter expert (internally and externally) on care management related matters.
Identifies, communicates, and escalates issues to the on a timely basis. Independently problem solves programmatic issues and implements appropriate solutions.
Serves as SME for, workflows/processes and initiatives related to care management programs and works with other business areas including IT, Clinical Informatics, Quality on business requirement development, JIVA Configuration, UAT.
May represents the programs in meetings with external auditors and regulators such as the Centers for Medicare/Medicaid Services (CMS), the Department of Children and Families (DCF), the Department of Health and Human Services (DHHS) and the Executive Office of Health and Human Services (EOHHS) as well as key providers related to program planning and implementation of programmatic changes.
Annually reviews and updates non-clinical policies, job aids and workflows for revision to meet model of care (MOC) changes, and to ensure continued regulatory and contractual compliance, best practices of care management.
In conjunction with Medical Management, leads efforts to ensure compliance with NCQA standards and new contractual obligations, ensuring opportunities for improvement are
identified and corrective action initiated within established timelines as required by the Accreditation Manager and Public Partnerships. Works with Clinical Trainer to incorporate regulatory requirement changes into ongoing training.
Prepares updated NCQA training for all CM staff at least on an annual basis.
Works with Finance to monitor performance.
Develops and oversees the production of standard reports to monitor and report on overall department metrics and care management program evaluation.
Accountable for tracking KPI metrics for care management goals and outcome targets where applicable and implementing operational changes in partnership with managers of care management as they relate to department metrics and clinical program performance.
Accountable for timely notification to leadership if performance falls below expectations. Collaborates with CM leadership to identify opportunities for improvement and implementation of interventions to address opportunities.
Supervision Exercised
N/A
Supervision Received
Weekly supervision with Manager of Care Management Operations
Qualifications
Education:
Bachelors degree or equivalent combination of education and relevant experience in a health plan setting required
Education Preferred/Desirable
Masters degree in Health-Related/Public Health field preferred.
Previous experience in Care Management strongly preferred
Experience
5+ years of healthcare/managed care experience.
5+ years project/ program management experience or other applicable work experience
Certification Or Conditions Of Employment
Pre-employment background check
Competencies, Skills, And Attributes
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.
Working Conditions And Physical Effort
Work is normally performed in a typical interior/office work environment.
Able to perform some work from a remote environment.
Fast-paced environment.
No or very limited physical effort is required. No or very limited exposure to physical risk
Regular and reliable attendance is an essential function of the position.
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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