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OCA & Supplier Operations Manager

WellSense Health Plan is a nonprofit health insurance company serving members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances.

Apply now (https://jobs.silkroad.com/BMCHP/Careers/Apply/MultiForm/294342)

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:

Under the direction of the Manager of OCA Operations, the OCA & Supplier Operations Manager is responsible as the service delivery manager for suppliers, supports OCA (Office of Clinical Affairs) performance, operations, and process improvement, and maintains accountability for projects and initiatives requiring engagement across multiple departments within OCA.

In support of clinical suppliers, OCA & Supplier Operations Manager owns the day to day operational oversight, performance management, and the service delivery of our supplier partners, including those suppliers which perform utilization management (UM) services on behalf of the health plan, as these supplier partners supplement and enhance the plan’s operational functions. This role will be the single point of contact for day-to-day management of clinical suppliers, and engage with internal stakeholders to develop a long-term clinical supplier strategy.

The OCA & Suppler Operations Manager is responsible for the overall management of clinical suppliers including but not limited to: Plan liaison, quality and performance oversight and management, ongoing communication with the suppliers, compliance with contractual and regulatory requirements, problem solving operational issues with input from subject matter experts, and expanding services in collaboration with UM or other business owner stakeholders. The OCA & Supplier Operations Manager serves as a vital resource to the business in its effort to ensure adherence to all State, Federal, and other regulatory standards

Our Investment in You:

· Full-time remote work

· Competitive salaries

· Excellent benefits

Key Functions/Responsibilities:

As the service delivery manager for OCA vendors and suppliers:

• Responsible for managing the operations and performance of the Plan’s clinical and utilization management (UM) supplier program that supplement and enhance the Plan’s operational functions.

• Supports supplier operational governance- joint operating committee, policy, procedures and corresponding materials including but not limited to onboarding and off boarding procedures, training procedures, quality measurement procedures, communication plans, and business continuity planning.

• Develops processes and metrics for monitoring supplier performance. Prepares metrics and analysis reporting to provide insights into supplier performance and identify opportunities to enhance performance of a team and/or process.

• Ensure that the business operations are in compliance with all applicable requirements of the contracts.

• Develops ongoing status reports regarding the actions, outcomes, and program details of the UM and clinical supplier program.

• Partners with the UM department, Sr. Medical Directors, care management as well as other key stakeholders to address pain points and improve member and provider experience.

• Participate in internal audits, research studies, forecasts, and modeling exercises to support business direction and guidance.

• Monitors supplier’s progress and compliance with any corrective action related to performance deficiencies. When necessary will work with the functional area managers and the Compliance team if other remediation or contractual impacts are required. Supports Appeals & Grievances on trends and implements effective improvements as applicable.

• Undertake process re-design and process improvement initiatives, obtain stakeholder input and build consensus, and implement new processes. Analyze KPIs to identify areas of opportunity, and create & execute action plans to improve the experience.

• Coordinate and lead supplier meetings to assess performance, ROI, operational issues, future planning and industry trends. Lead calibration sessions with UM/clinical supplier partners to align on the evaluation processes and improve quality scores.

• Collaborate with business owners and Finance subject matter experts to develop ROI methodologies and financial value analyses that support UM/clinical strategy decisions. Manage actual expenses against expected costs and audit all UM/clinical supplier invoices.

• Provides business leadership and coordination on UM/clinical supplier related RFPs to source new services and ensure contracted services remain cost competitive with high performing SLAs.

• Provides support to Legal and Compliance and coordinates compliance efforts with functional area managers.

• Coordinates with operational partners to provide information to UM/clinical partners about new features or products.

• Develop and communicate to plan leadership a supplier roadmap, governance plan, strategy, and metrics of success.

• Supports projects or work streams which require multiple points of engagement across OCA departments

• Assesses and develops programming to support operational and management activities within OCA aligned to strategic priorities and objectives

• Works with Finance to monitor performance across OCA programs and initiatives

• Identifies opportunities to improve existing operational policies and procedures and develops new policies and procedures as necessary.

• Identifies, communicates, and escalates issues on a timely basis. Independently problem solves programmatic issues and implements appropriate solutions.

• Provides consultation on annual review and updates of departmental policies, job aids and workflows for revision to meet model of care (MOC) changes, and to ensure continued regulatory and contractual compliance

• Stays up to date on varying products’ model of care, and the impact across OCA as changes are made

• Facilitates cross-functional internal stakeholders, (customer service, marketing, product, finance, care management, utilization management, pharmacy, behavioral health) to ensure operational requirements are developed to support OCA objectives

Supervision Exercised:

• None

Supervision Received:

• General supervision is received weekly.

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 business or health related/public health field preferred

Experience:

• 5+ years of healthcare/managed care experience.

• 5+ years project/ program management experience or other applicable work experience

• Working knowledge of regulatory requirements in a healthcare environment (FDRs, CMS, NCQA, URAC, etc.)

• Experience in CMS Medicare products, Medicaid, or both preferred

Certification or Conditions of Employment:

• Successful completion of 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.

• Conflict management and team building. 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 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.

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

Apply now (https://jobs.silkroad.com/BMCHP/Careers/Apply/MultiForm/294342)

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