Join WellSense Health Plan and play a key role in ensuring fair, timely, and compliant resolution of member appeals and grievances. This position is perfect for someone with managed care experience who thrives in a detail-driven, regulatory environment.
About WellSense Health Plan
WellSense 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 affordable, high-quality health plans that meet people where they are. With over 25 years of service, we are dedicated to health equity, inclusion, and better outcomes for our members.
Schedule
- Full-time, remote position
- Standard business hours, Monday–Friday
- Occasional cross-department collaboration and regulatory deadlines
What You’ll Do
- Manage resolution of member medical and pharmacy appeals, complaints, and grievances
- Ensure compliance with CMS, MassHealth, DHHS, and NCQA accreditation requirements
- Act as liaison with state and federal agencies, external vendors, and medical review boards
- Draft and issue appeal determination and resolution letters
- Investigate and document member grievances, including quality of care concerns
- Collaborate with clinical staff and internal teams to implement corrective action plans when necessary
- Maintain accurate reporting and documentation for audits and regulatory review
- Identify trends and recommend improvements to policies, processes, and compliance standards
What You Need
- Bachelor’s degree in Healthcare Administration or related field (or equivalent experience)
- 2+ years’ experience in a managed care organization
- Direct experience with Medicare appeals, grievances, or prior authorization processes
- Strong knowledge of CMS, MassHealth, DHHS, and NCQA accreditation requirements (preferred)
- Skills in conflict resolution and customer service
- Proficiency with Microsoft Office (Word, Excel, Outlook)
- Strong verbal and written communication, with high attention to detail
- Bilingual skills highly desirable
Benefits
- Competitive salary
- Comprehensive health and retirement benefits package
- Remote flexibility with career growth opportunities
- Inclusive, mission-driven work culture
- Paid time off and recognition programs
Make a difference by protecting member rights and ensuring compliance in healthcare appeals and grievances.
Your voice matters here—help WellSense deliver fair and timely resolutions.
Happy Hunting,
~Two Chicks…