Use your clinical expertise to protect members, elevate care quality, and ensure fair outcomes for behavioral health and substance use appeals and grievances.
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 accessible Medicare, Medicaid, and Individual/Family plans designed to support people through every circumstance. Our mission is simple: health coverage that works for everyone.
Schedule
• Full-time, remote role
• Standard business hours with cross-functional collaboration
• Occasional travel required
What You’ll Do
• Audit medical necessity appeal decisions to ensure accuracy, compliance, and clinical soundness
• Support grievance intake, investigation, and resolution; identify trends and improvement opportunities
• Ensure timely resolution of clinical appeals, administrative appeals, and grievances
• Assist with correspondence to members and providers
• Provide coaching and performance feedback to staff based on quality trends
• Lead and participate in calibration sessions to maintain consistency and accuracy in audit standards
• Recommend and document process enhancements that improve quality and compliance
• Identify workflow defects, inconsistencies, and risk areas
• Maintain deep knowledge of internal policies, regulatory requirements, and accreditation standards
• Serve as subject matter expert on behavioral health and substance use topics
• Collaborate with cross-functional partners across Appeals, Grievances, Clinical, and Quality teams
• Support regulatory reporting, universe preparation, and audit presentation
• Perform additional duties as assigned
What You Need
• Registered Nurse with an active, unrestricted RN license
• Associate or Bachelor’s degree in Nursing, or a Diploma in Nursing
• 3+ years of managed care healthcare experience
• Strong foundation in behavioral health, substance use, crisis intervention, and psychopharmacology
• Experience with payer medical guidelines, including MCG and/or InterQual
• Working knowledge of psychiatric and addiction treatment protocols
• Familiarity with BH inpatient/outpatient settings, interdisciplinary treatment teams, and continuum of care
• Strong communication, organization, de-escalation, and problem-solving skills
• Excellent analytical ability and comfort interpreting metrics and data
• Proficiency with Microsoft Office
• Experience working with diverse populations
• Bilingual candidates encouraged to apply
Preferred
• BSN
• ANCC Certification in Psychiatric–Mental Health Nursing
• Prior psychiatric nursing or substance use treatment facility experience
• Knowledge of Medicare/Medicaid regulations and NCQA requirements
Benefits
• Competitive salary range: $69,500–$100,500 (adjusted by geography and experience)
• Full medical, dental, vision, and pharmacy coverage
• 403(b) with employer match
• Merit increases and advancement opportunities
• Flexible Spending Accounts
• Paid time off
• Wellness resources for employees and families
Join a mission-driven care team improving outcomes for members who need strong behavioral health advocacy the most.
Happy Hunting,
~Two Chicks…