Use your detail mind and people skills to stand up for members when something goes wrong with their care. In this fully remote role, you will handle appeals and complaints that genuinely impact access, coverage, and trust.
About WellSense Health Plan
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 in 1997 as Boston Medical Center HealthNet Plan, WellSense focuses on delivering high quality coverage that works for members regardless of their circumstances. The organization is committed to equity, inclusion, and doing right by the communities it serves.
Schedule
- Position type: Full time, remote
- Work setting: Home office with secure, distraction free environment
- Department: Appeals and Grievances within a managed care organization
What You’ll Do
- Manage the full resolution process for medical and pharmacy member appeals and member generated complaints and grievances.
- Coordinate appeals across internal departments and external vendors, setting processing schedules and guidelines on a case by case basis.
- Ensure compliance with CMS, MassHealth, DHHS, and other regulatory and contractual requirements, including NCQA accreditation standards.
- Serve as a liaison with external entities such as IRE, QIO, Office of Medicaid’s Board of Hearing, NH State Fair Hearing, Department of Public Health, and Health Policy Commission.
- Draft, issue, and document appeal determination letters and grievance resolution letters with clear, accurate explanations.
- Investigate quality of care grievances in collaboration with clinical staff and support corrective action plans when needed.
- Maintain organized, high quality documentation for all appeals, complaints, and grievances, and support internal and external reporting needs.
- Identify trends, share findings with other departments, and help shape improvement plans across the organization.
What You Need
- Bachelor degree in Health Care Administration or related field, or an equivalent mix of education, training, and experience.
- At least 2 years of experience in a managed care organization.
- Hands on experience with Medicare medical or pharmacy prior authorization and appeals and grievances processes.
- Strong knowledge of CMS, MassHealth, DHHS provisions and NCQA accreditation standards is highly desirable.
- Demonstrated ability to plan, organize, and manage projects within a managed care environment.
- Critical thinking skills and independent decision making ability.
- Strong written and verbal communication skills, with excellent attention to detail.
- Good customer service skills and experience working with diverse populations.
- Working knowledge of Microsoft Office and basic health care terminology.
- Bilingual ability is preferred.
Benefits
- Full time remote work for a mission driven, nonprofit health plan.
- Competitive salary and excellent benefits package.
- Generous paid time off and paid holidays.
- 403(b) savings with company support.
- Opportunities for career growth inside a respected regional health plan.
Remote roles that blend compliance, member advocacy, and real impact do not sit open for long.
If you are ready to be the person who makes sure members are heard and regulations are respected, this is your move.
Happy Hunting,
~Two Chicks…