Support compliance and member advocacy by managing appeals and grievances for a nonprofit health plan serving Massachusetts and New Hampshire.
About WellSense Health Plan
WellSense Health Plan is a nonprofit insurer serving more than 740,000 members across Massachusetts and New Hampshire. Founded in 1997 as Boston Medical Center HealthNet Plan, WellSense provides high-quality Medicare, Medicaid, and Individual/Family plans. The organization is committed to diversity, equity, and inclusion, ensuring health insurance that works for members—no matter their circumstances.
Schedule
- Full-time, remote (U.S.)
- Monday–Friday schedule with flexibility based on workflow
- Collaboration across multiple internal departments and external agencies
Responsibilities
Appeals
- Manage and execute member appeals across medical and pharmacy services
- Coordinate with CMS, MassHealth, DHHS, IRE, QIO, and other external agencies
- Ensure compliance with federal, state, and accreditation standards (CMS, NCQA, etc.)
- Draft, issue, and communicate appeal determinations to members and providers
- Support audits and reporting requirements
Grievances
- Coordinate and resolve member complaints and grievances with internal teams and external vendors
- Investigate quality-of-care concerns with clinical staff and support corrective action plans
- Write and review grievance resolution letters
- Identify trends and support organizational improvement plans
Requirements
- Bachelor’s degree in Healthcare Administration or related field (or equivalent experience)
- 2+ years of experience in a managed care organization
- Experience with Medicare prior authorization, appeals, and grievance processes
- Knowledge of CMS, MassHealth, DHHS, and NCQA requirements
- Strong critical thinking, organizational, and conflict resolution skills
- Excellent written and verbal communication skills
- Proficiency with Microsoft Office
- Bi-lingual skills preferred
Benefits
- Competitive salary
- Full remote work opportunity
- Comprehensive benefits package (medical, dental, vision)
- 401(k) with match
- Paid time off and holidays
- Tuition assistance and professional development programs
- Inclusive workplace culture supporting diverse populations
WellSense is an Equal Opportunity Employer and participates in E-Verify.
Happy Hunting,
~Two Chicks…