UM Operations Program Manager

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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

The UM Operations Program Manager is responsible for managing department systems changes, testing and implementation across all teams. Evaluates end to end processes supported through systems and makes recommendations for improvements. Accountable for leading and implementing multiple initiatives to build the Department’s infrastructure with a focus on IT integration, including those activities with a focus on process improvement or in response to the Plan’s growth. Primary department contact working with providers, Provider Engagement, IT and other internal departments to increase providers’ adoption of the Plan’s portal. Responsible for UM reporting function.

Our Investment In You

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

Key Functions/Responsibilities

• Works with Subject Matter Experts (SMEs) across all department teams to identify needed system changes for process improvements and new product implementations.
• Reviews new system solutions and capabilities including further automation of existing processes and integration with provider systems. Leads departmental initiatives for improved automation.
• Creates testing plans, works with SME to perform testing accurately and timely. Leads testing, all Jiva changes. Works with IT to report and resolve defects and re-test as needed. Facilitates regression testing sessions after ZeOmega releases.
• Assists with development, and reviews internal and external business specifications documents.
• Develops departmental targets, measures and metrics and integrates their use across all department functions and team members. Assures reporting to support metrics monitoring.
• Works with UM Trainer to document new process changes; performs role as SME for training sessions for system changes.
• In conjunction with Provider Engagement, leads conversion from fax to HT submissions. Tracks progress and reports to HT Workgroup. Supports Provider Engagement in provider meetings.
• As centralized business lead for conversion effort, identifies issues and submits for IT resolution. Tracks and reports to HT Workgroup.
• Oversees department’s work to resolve claims issues; recommends changes to process and software to address process improvements.
• Other duties as assigned.
  
  

Supervision Exercised

• None
  
  

Supervision Received

• General supervision is received.
  
  

Qualifications

Education Required:

• Bachelor’s Degree in Healthcare area, or the equivalent combination of training and experience is required.
  
  

Education Preferred

• Master’s Degree in Healthcare or related field
• Lean or Six Sigma certification - preferred but not required
  
  

Experience Required

• Demonstrated knowledge of UM functionality in Jiva, Facets, Health Trio and Electronic Medical Records Systems or other UM systems functionality.
• Demonstrated knowledge of authorization processes and UM NCQA and contractual requirements.
• Experience with developing business requirements.
• 3 years of experience in a Utilization Management or like role
• 5 years of experience with Medicaid/Medicare Managed Care or other health plan experience
  
  

Required Licensure, Certification Or Conditions Of Employment

• Pre-employment background check
  
  

Competencies, Skills, And Attributes

• Understands multiple systems capabilities and uses knowledge to identify and prioritize changes with greatest impact.
• Effective collaborative and process improvement skills.
• Strong oral and written communication skills; ability to interact within all levels of the organization.
• A strong working knowledge of Microsoft Office products.
• Knowledge of process improvement techniques
• Demonstrated ability to successfully plan, organize and manage projects.
• Detail oriented, excellent proof reading and editing skills.
  
  

Working Conditions And Physical Effort

• Work is performed fully remotely.
• No or very limited physical effort 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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