WellSense Health Plan

Perform detailed medical record audits of outpatient and professional claims to ensure accurate reimbursement and regulatory compliance. Identify billing discrepancies, analyze clinical data trends, and provide recommendations for audit improvements.

Lead the strategic direction of the supplier procurement and management organization to optimize partner performance and value. Oversee the end-to-end supplier lifecycle, including selection, contracting, and regulatory compliance within a healthcare environment.

Responsible for the documentation, operational oversight, and analysis of non-clinical care management programs to ensure regulatory compliance. Acts as a subject matter expert to lead workflows and coordinate between IT and clinical teams for system configurations and reporting.

Responsible for the accurate and timely processing and adjudication of health insurance claims according to company policies. This includes reviewing system-generated reports to resolve errors and maintaining knowledge of Medicaid regulations and provider contracts.

The Contract Manager facilitates the development, implementation, and management of cost-effective provider networks while leading contract language and reimbursement negotiations. They also ensure provider compliance with regulatory standards and analyze network performance to improve cost and quality outcomes.

This role is primarily responsible for leading, coaching, and motivating a team of Member Services and Provider Services supervisors and staff, aiming to deliver high-quality, timely, and accurate service to members and providers. The manager will also analyze operational trends, monitor KPIs, and implement strategies to improve satisfaction and efficiency across service lines.