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.

Job Summary:

Reporting to the Manager of Care Management Operations, the Operations Manager is responsible for documentation of care management processes and 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:

• In collaboration with the Regulatory Program Manager, responsible for analyzing the impact of accreditation and regulatory changes and makes recommendations on programmatic operational changes to ensure compliance.

• Develops, maintains, stores and communicates non-clinical policies, standard operating procedures and job aids for the CM department in collaboration with subject matter experts and business owners.

• Annually reviews and updates non-clinical policies, standard operating procedures and workflows for needed revisions to meet model of care (MOC) changes; to ensure continued regulatory and contractual compliance; and to reflect best practices of care management.

• Manages non-clinical operations for Care Management teams, including implementation of effective metrics to monitor productivity and compliance.

• Serves as operations subject matter expert and leads workflows/processes and initiatives related to care management programs in collaboration with other business areas including but not limited to IT, UM, AG, Clinical Informatics, Quality, Public Partnerships, Marketing, Product and Transformation teams.

• Liaison between IT and clinical to make system configuration and reporting changes including submitting requests and planning/ overseeing user acceptance/ regression testing.

• In collaboration with the clinical care management leadership team, represents the CM programs in complex cross-functional teams and projects as the subject matter expert (internally and externally) on care management related matters.

• Facilitates meetings and decision making as well as identifies scalability opportunities.

• Identifies, communicates, and escalates issues to leadership on a timely basis.

• Independently problem solves programmatic issues and implements appropriate solutions.

• Supports clinical with audits from documentation preparation through operationalizing corrective action plans.

• Liaison between clinical and reporting teams for development 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.

Supervision Exercised:

• N/A

Supervision Received:

• Weekly supervision with Manager of Care Management Operations

Qualifications:

Education:

• Bachelor’s degree or equivalent combination of education and relevant experience in a health plan setting required.

Education Preferred/Desirable:

• Master’s 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 Teams and 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.

Compensation Range

$86,500- $125,500

This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.

Note: This range is based on Boston-area data, and is subject to modification based on geographic location.

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