Help ensure members receive fair, timely, and compliant resolutions to their appeals and grievances while supporting a mission-driven health plan dedicated to equitable care.
About WellSense Health Plan
WellSense is a nonprofit health insurance plan serving more than 740,000 members across Massachusetts and New Hampshire. For over 25 years, we’ve delivered dependable Medicare, Medicaid, and Individual/Family coverage designed to meet people where they are. We’re committed to fairness, accessibility, and high-quality service for every member.
Schedule
• Full-time, remote
• Standard business hours
• Collaboration across Appeals, Grievances, Clinical, and Compliance teams
Responsibilities
Appeals
• Process member medical and pharmacy appeals across internal teams and external vendors
• Create appeal schedules and determine case-by-case processing guidelines
• Ensure compliance with CMS, MassHealth, DHHS, and other regulatory requirements
• Serve as liaison with IRE, QIO, Medicaid Fair Hearing Boards, and other oversight entities
• Maintain compliance with Qualified Health Plan and commercial plan regulations
• Support NCQA accreditation standards through documentation and process adherence
• Participate in appeals audits and recommend improvements
• Draft and issue appeal determination letters
• Communicate results with members, providers, and medical personnel
• Prepare reports, research case data, and ensure documentation accuracy
• Assist with required reporting to regulatory agencies
Grievances
• Coordinate complaint and grievance investigations with internal teams and vendors
• Collaborate with clinical staff on quality-of-care grievance reviews and action plans
• Respond to member concerns, complete investigations, and issue resolution letters
• Maintain compliance with regulatory guidelines and documentation standards
• Identify trends and partner on improvement plans across departments
Requirements
Education
• Bachelor’s degree in Healthcare Administration or related field
• Equivalent experience may be considered
Experience
• 2+ years in a managed care organization
• Required experience with Medicare medical/pharmacy prior authorizations, appeals, and grievances
• Strong understanding of CMS, MassHealth, DHHS, and NCQA guidelines preferred
• Conflict resolution experience highly preferred
Skills
• Strong project management and organization skills
• Excellent verbal and written communication
• Independent decision-making and critical thinking
• Proficiency in Microsoft Office
• Ability to collaborate with diverse internal teams and member populations
• Detail-oriented and customer-service focused
• Bilingual candidates encouraged to apply
Benefits
• Full-time remote work
• Competitive salary
• Comprehensive benefits package
• Opportunities for advancement within a mission-driven organization
Make a real impact by helping members receive fair and compassionate resolutions during their most important moments.
Happy Hunting,
~Two Chicks…