Provider Network Director jobs in Springfield, MA

Wellfleet, a Berkshire Hathaway company, delivers customer-centric accident and health insurance, with quality service and uncompromising ethics. Wellfleet works to protect people against risk throughout every stage of life – from grade school to college to the workplace.

Founded in 1993 as Consolidated Health Plans (CHP), Wellfleet, headquartered in Springfield, Mass., is one of the nation’s leading providers of health and accident insurance products to the higher education market.

The ideal person in this position will have experience working in the health insurance industry and be familiar with PPO Network operations and applying them to practical daily operations. The ideal candidate should also be familiar with provider contracting, provider relations, provider billing, coding and appeals.

In this role, you will…

• Research, respond (by phone and email) and track inquiries in a timely manner that come into the Provider Relations mailbox
• Have the ability to reprice claims in LuminX system for all networks
• Have the ability to add and maintain LuminX provider records for all school plans; Provider maintenance updates are part of the Provider Department’s Key Performance Metrics and are routinely monitored
• Call providers to obtain updates for Tax ID numbers and W9 forms
• Have the ability to work the LuminX mailbox within turnaround time standards so claims team can meet prompt pay claim requirements per State Law
• Handle Electronic Data Interchange (EDI) claim rejections and work with PPO networks to get pricing and apply manual repricing as needed
• Coordinate with cost-containment vendor on claim edits and audits, claim cancellations, and appeals
• Handle Provider Appeals by researching and using analytical skills to evaluate facts and work with provider networks and vendors to resolve appeals. Maintain tracking spreadsheet to monitor number of appeals
• Be able to research issues with and process provider returned checks  
• Participate in PPO Network and vendor quarterly oversight calls/meetings as needed
• Have the ability to work on remote claim repricing when networks are beyond expected turnaround times
• Research provider reimbursement inquiries related to provider agreements with clients and PPO networks using PPO network/vendor portals
• Cross train on all provider network tasks within the department
• Create and maintain process documentation for tasks performed by the Provider Network Team
• Provide assistance to the Head of Provider & Network Management and the Provider Network Manager on ad hoc projects that support provider network and benefit the company as a whole
• Perform other duties as assigned

We are looking for candidates with…

• Associate’s degree in Health Administration, Business Administration, or an equivalent combination of education and work experience in related field.
• Two to three years of experience working in health insurance industry with focus on medical provider contracting, relations, and/or medical provider billing and coding
• Exemplary Customer service experience
• Excellent skills in the following areas: verbal/written communication, attention to detail and be accountable and take ownership of all work, multi-tasking
• Ability to work independently and as a member of the team
• Ability to maintain composure and diplomacy in negotiations and when under pressure or challenged
• Detailed orientated problem solver with excellent time management skills
• Proficiency with MS Office products to include Outlook, Excel, and Word
• Health insurance industry experience preferred.

Why Wellfleet?

Here at Wellfleet, we foster a culture of growth that enables engaged and high-performing professionals to be empowered to deliver our mission and vision.

Our employees are a team devoted to providing customer service that exceeds expectations of our members and clients. Successful team members continually look for ways to improve product delivery and value.

Wellfleet offers a competitive compensation package and comprehensive benefits package including life, health and dental, vision, 401K retirement plan, short- and long-term disability coverage, flexible/dependent care spending account, tuition reimbursement, and business casual dress.

Are you interested in exploring a career at Wellfleet? Explore our open positions.

General:

Wellfleet is part of the MedPro Group family. As such, all Wellfleet team members are employees of MedPro Group Inc. We are an Equal Opportunity Employer. The base hourly range is $20.00 to $22.00.  This range anticipates the low and high end of the wages for this position. Actual wages will vary and are based on factors such as a candidate’s qualifications, skills and competencies.  Wages are one component of Wellfleet’s total compensation and benefits package, which includes medical, vision and dental insurance options, life and accident insurance, 401(k), and short-term and long-term disability insurance. For a more detailed overview, visit our careers website at: wellfleetinsurance.com/about/careers. #LI-KS1 #LI-SS1 #LI-OnSite