Provider Enrollment Representative

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.

This role plays a pivotal part in the Network Management team, being accountable for the enrollment and upkeep of both new and existing Contracts. Operating at the core of the team's responsibilities, the position focuses on facilitating a seamless enrollment experience for individual providers, groups, facilities, IPAs, MSOs and PHOs. Responsibilities include meticulously reviewing and analyzing application operations and enrollment processes, ensuring compliance with required timeframes for timely and accurate provider enrollment. The ideal candidate possesses strong organizational skills, excels in varied and dynamic work environments, and has the ability to independently organize and prioritize workloads to effectively support the goals of the Plan. Additionally, the role requires a high degree of maturity, discretion, and an unwavering commitment to maintaining confidentiality.

Our Investment In You

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

Key Functions/Responsibilities

• Responsible for accurately completing the enrollment/re-enrollment processes of providers as identified through department policies, network reimbursement and delegated contracts to ensure timely and continued provider participation.
• Maintains detailed provider enrollment files in electronic format, including electronically received documents, scanning of hard copy documents and documents each state of the enrollment/re-enrollment process thoroughly. Proactively initiates oversight of existing provider record issues/problems, or actively coordinates the resolution of issues identified by external stakeholders and/or provider. Identifies active or potential system problems with provider set up and coordinates resolution to facilitate accurate provider payments.
• Coordinates updates and communication between provider(s) and appropriate stakeholders that includes follow-up communications, concise issue resolution and the collection and distribution of all necessary documents and forms in a timely manner.
• Adheres to policies and procedures including data security and HIPAA requirements.
• Utilizes the Onyx database, optimizing efficiency, and performs document generation; Assists in trouble-shooting provider participation interruptions.
• Acquires and demonstrates a thorough knowledge of contractual arrangements and payment methodologies, in order to appropriately interpret contract terms and apply corresponding agreement terms to ensure providers are paid correctly from the beginning of their affiliation with the Plan.
• Ensures the quality, completeness and accuracy of provider data for the purposes of ensuring compliance with Medicare and Medicaid regulations and guidelines.
• Work closely with credentialing team to coordinate enrollment efforts and meet appropriate deadlines as a team.
• Independently initiates oversight of existing provider record problems. Identifies system problems with provider set up and facilitates resolution so that provider payments are accurate.
• Coordinates set up and hand off of provider records to Credentialing Department. Completes provider data input and assures data forms are completed per company requirements.
• Reviews submitted application and supporting documentation to ensure the data captured through the enrollment process is in compliance with NCQA, applicable state requirements.
• Follows established contracting process to ensure the smooth implementation of the provider contracts. Tracks, maintains and communicates information pertaining to the status of contracts in accordance with the established contracting process.
• Researches, facilitates and assists with resolution of interdepartmental issues related to enrollment as identified by providers and internal staff.
• Maintains the integrity of Provider Data in Onyx. Provides assistance with ongoing quality initiatives related to improved data processing and workflows. Keeps current regarding any changes in managed care payor requirements for provider enrollment and participates in ongoing training sessions.
• Provides system analysis support as needed to ensure operational compliance with Plan provider and database rules.
• Other duties as assigned by manager.
  
  

Qualifications

Education:

• Bachelor’s degree or an equivalent combination of education, training and experience is required
  
  

Experience

• 2 or more years business experience in a managed care or healthcare setting is required
  
  

Competencies, Skills, And Attributes

• Ability to work as a team member, to manage multiple tasks, to be flexible, and to work independently and possess excellent organizational and problem solving skills
• Ability to accurately enter, proof, submit data and to identify inaccurate data and process to resolution
• Demonstrated competence using Microsoft Office products especially Word, Excel, Outlook, Access, PowerPoint
• Experience or knowledge of ONYX, FACETS and/or similar provider data and/or claims processing system
• Effective communication skills (verbal and written)
  
  

Working Conditions And Physical Effort

• Ability to work OT during peak periods
  
  

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.

Required Skills

Required Experience