Use your RN license and clinical judgment to make sure members get the right care at the right time. In this fully remote role, you will review hospitalizations, home care, and medical services for medical necessity so members receive appropriate, timely treatment and the plan stays in compliance.
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 providing high quality coverage that works for members, no matter their circumstances. The organization is committed to equity, inclusion, and better health outcomes for the communities it serves.
Schedule
- Position type: Full time, remote
- Work setting: Home office with secure, distraction free environment
- Licensure: Active RN license in New Hampshire or a compact state that includes NH
- Additional expectations: Ability to take after hours call, including evenings, nights, and weekends
- Occasional travel: Possible travel to the Charlestown, Massachusetts office for meetings or training
What You’ll Do
- Review inpatient and outpatient services, hospitalizations, and home care for medical necessity using InterQual criteria, medical policy, and member benefits.
- Perform utilization review activities, including pre certification, concurrent review, and retrospective review according to guidelines and regulatory timelines.
- Apply evidence based guidelines and clinical criteria to first level reviews and determine coverage for medically necessary services.
- Document and communicate all utilization review activities, decisions, and case communications clearly and completely.
- Refer cases to Physician Reviewers when requests do not meet criteria or when guidelines are not available, allowing time for provider contact within mandated turnaround times.
- Send appropriate system generated decision letters to providers and members.
- Provide guidance and coaching to other utilization review nurses and support orientation of new utilization staff.
- Follow departmental workflows and policies in the end to end management of prior authorization cases.
- Participate in team meetings, audits, education sessions, and process improvement discussions.
- Maintain compliance with federal, state, and accreditation requirements and identify opportunities for better communication or workflow.
- Accurately document rate negotiation details for claims adjudication and identify cases for referral to Care Management.
What You Need
- Nursing degree or diploma required; bachelor degree preferred.
- Active, unrestricted RN license in NH or a compact eligible state that includes NH.
- At least 2 years of prior authorization experience using evidence based guidelines, such as InterQual.
- Managed care experience and knowledge of Medicare and Medicaid regulations.
- Strong clinical judgment and critical thinking skills to assess complex cases and determine appropriate levels of care.
- Excellent written and verbal communication and interpersonal skills for working with providers, internal staff, and external partners.
- Ability to work independently in a remote environment while meeting timelines and regulatory requirements.
- Proficiency with Microsoft Office and comfort working in data and case management systems.
- Strong organizational and time management skills in a fast paced, dynamic setting.
- Ability to pass a pre employment background check and comply with telecommuter policies.
Benefits
- Full time remote role with hourly pay in the range of 35.58 to 51.44 dollars, depending on experience, location, education, and credentials.
- Comprehensive 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.
- Career growth and advancement opportunities within a mission driven nonprofit health plan.
- Resources and programs that support the wellbeing of you and your family.
Clinical remote roles that combine autonomy, impact, and stable benefits do not stay open for long.
If you are ready to use your RN license to advocate for appropriate care from the utilization side, this is your signal to move.
Happy Hunting,
~Two Chicks…