Director of Member and Provider Service

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 Director of Member and Provider Service is a strategic, data driven, results-oriented leader. This leader is responsible for overseeing and evolving the member and provider contact center operations across Medicaid, Medicare, and ACA lines of business in Massachusetts and New Hampshire. This role ensures a high-quality, efficient, and personalized experience across all customer touchpoints while driving continuous improvement through data, technology, and employee engagement. The Director will lead the transformation of service delivery using modern customer experience (CX) practices-including AI, omnichannel engagement, self-service tools and real-time analytics-while ensuring full compliance with regulatory and contractual obligations.

Our Investment in You:

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

Key Responsibilities

• Provide strategic and operational leadership of the Member and Provider Service Contact Center, ensuring delivery of accurate, empathetic, and timely service experiences.
• Develop and execute multi-year plans to evolve the contact center from a transactional model to a proactive, relationship-driven, omnichannel experience.
• Implement innovative tools (AI, chatbots, voice analytics, CRM systems, etc.) to optimize performance, reduce effort, and personalize service.
• Identify and lead service improvement initiatives using Voice of the Customer (VoC), root cause analysis, and customer journey mapping.
• Partner with Workforce Planning and Recruiting to maintain appropriate staffing across lines of business to ensure optimal service levels and adherence to regulatory requirements.
• Utilize real-time and historical analytics to optimize performance, forecast demand, and drive process improvements.
• Lead employee engagement, retention, and development strategies through coaching, performance management, and robust career pathing.
• Foster a culture of accountability, recognition and high performance aligned with company values and a customer-first mindset.
• Build and manage annual budgets, providing sound business cases for capital investments, organizational alignment and staffing resources.
• Collaborate with internal business partners to support corporate objectives, customer needs and regulatory requirements.
• Ensure full adherence to federal and state regulatory requirements, including those from CMS, EOHHS, DHHS, NCQA, and contractual obligations.
• Lead the development and documentation of operational policies, procedures, and business continuity plans.
• Serve as the executive point of contact for member advisory committees, public forums and partner feedback loops.

Supervisory Responsibilities

• Direct Reports: 4-7 contact center, operational and quality managers
• Indirect Oversight: 200-300 contact center and supporting positions across various lines of business and service channels

Reporting Structure

• Reports to the Senior Vice President, Service & Operations

Qualifications

Education:

• Bachelor's degree in Business Administration, Operations, Health Care Management, or related field required.
• Master's degree (MBA, MHA, or similar) preferred.

Experience:

• Minimum 10 years of progressive leadership experience in a contact center/customer service environment, including at least 5 years in a healthcare or managed care setting.
• Deep knowledge of Medicaid/Medicare operations, service delivery models, contact center metrics, contact center channels, telephony and CRM platforms.
• Demonstrated success in leading transformational initiatives including digital enablement, omnichannel strategy, and automation.
• Demonstrated improvement in customer experience, employee satisfaction, contact center efficiencies and operational performance.
• Experience managing within regulated environments and responding to audits, compliance reviews and performance guarantees.

Key Competencies & Skills

• Customer-Centric Leadership: Committed to delivering exceptional experiences through empathy, innovation, and a strong operational focus.
• Continuous Improvement Mindset: Proactively identifies opportunities to streamline processes, enhance performance, and elevate service quality in dynamic, high-volume environments.
• CX & Tech Fluency: Deep understanding of contact center technologies including ACD, IVR, cloud-based solutions, AI chat, real-time analytics, and WFM platforms.
• Strategic Execution: Results-driven with strong business acumen; adept at aligning service operations with organizational goals to drive measurable outcomes.
• Regulatory Insight: Well-versed in applying federal and state healthcare regulations to ensure compliance and operational integrity.
• Resilience & Agility: Thrives under pressure and effectively manages competing priorities in fast-paced settings without losing sight of quality or service standards.
• Collaborative Leadership: Skilled in influencing across matrixed teams, fostering alignment, and building consensus in complex organizational structures.
• Data-Driven Decision Making: Leverages analytics to identify trends, monitor KPIs, and implement targeted improvements that enhance both experience and efficiency.
• Talent Development: Demonstrated ability to lead, develop, and retain high-performing individuals and leadership teams in a performance-oriented culture.

Work Environment

• Remote position
• Occasional travel for in-person leadership meetings, project work and strategic planning sessions
• Eastern time zone office hours
• Standard office environment with minimal physical demands

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