Use your pharmacy know how and people skills to keep medications moving smoothly for members who rely on them every day. This full time, work from home role lets you support prior authorizations and pharmacy operations without stepping behind a retail counter.
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 high quality coverage that works for members, no matter their circumstances, and is firmly committed to diversity, inclusion, and equitable care.
Schedule
- Position type: Full time, remote
- Work setting: Home office with reliable high speed internet and minimal distractions
- General expectations: Standard business hours with flexibility based on team needs
- Work style: Phone, email, and system based support for internal and external stakeholders
What You’ll Do
- Receive, process, and review prior authorization requests by phone, fax, and electronic systems in line with regulatory and accreditation requirements.
- Apply clinical policy criteria to determine whether medication requests meet coverage guidelines.
- Review member eligibility, claims history, and pharmacy benefit information using PBM claims software.
- Interpret medical and pharmacy data and enter accurate information into internal systems according to NCQA and regulatory standards.
- Communicate determinations and updates to members and providers via phone, fax, and written notifications.
- Provide pharmacy related customer service for both internal teams and external partners.
- Process pharmacy authorizations using PBM real time online claims adjudication tools.
- Support the administration of the formulary and benefits by analyzing issues and helping resolve them.
- Serve as a go to resource for Member Services and other teams on pharmacy benefit, policy, and plan design questions.
- Assist with new clinical program implementations and handle other pharmacy operations duties as needed.
What You Need
- Minimum of a high school diploma or equivalent; associate or bachelor degree preferred.
- At least two years of experience in a professional or pharmacy setting.
- Experience in a managed care environment preferred.
- Prior customer service experience, especially assisting members or providers by phone, is a plus.
- Strong customer service mindset with a calm, helpful approach.
- Excellent written and verbal communication skills.
- Strong data entry skills and attention to detail when building and documenting cases.
- Solid organizational and problem solving skills with the ability to multitask and stay results focused.
Benefits
- Hourly pay range of approximately 20.19 to 28.13 dollars, based on experience, location, and qualifications.
- Comprehensive benefits package including medical, dental, vision, and pharmacy coverage.
- Paid time off, paid holidays, and merit increase opportunities.
- Flexible Spending Accounts and 403(b) savings plan with matches.
- Full time remote work with the backing of a stable, mission driven health plan.
- Career growth opportunities and resources that support your wellbeing and long term development.
If you want a remote role where your pharmacy experience actually matters and your attention to detail protects real people, this is one to move on while it is open.
Happy Hunting,
~Two Chicks…