by Terrance Ellis | Nov 20, 2025 | Uncategorized
Play a key role in strengthening healthcare quality across Massachusetts and New Hampshire. This remote role helps drive accurate HEDIS reporting, regulatory compliance, and measurable quality outcomes for members.
About WellSense Health Plan
WellSense is a nonprofit health insurance company serving more than 740,000 members across MA and NH through Medicare, Medicaid, and Individual/Family plans. Founded in 1997, we’re committed to delivering high-quality, equitable healthcare and supporting members no matter their circumstances.
Schedule
- Full-time, fully remote
- Standard business hours with flexibility based on provider outreach and reporting timelines
- Must maintain reliable attendance and meet accuracy and productivity standards
What You’ll Do
⦁ Perform medical record abstraction and data entry for NCQA HEDIS and other audit-based measures
⦁ Maintain ≥90% inter-rater reliability accuracy and complete yearly testing
⦁ Conduct overreads to validate accuracy, consistency, and compliance with technical specifications
⦁ Navigate multiple EMR systems (Epic, Cerner, Allscripts) to retrieve and abstract medical records
⦁ Build and maintain strong relationships with provider partners to ensure timely record retrieval
⦁ Research member and claims data using internal systems to validate service information
⦁ Support chart procurement efforts and maintain a retrieval rate of ≥95%
⦁ Assist with training on HEDIS measures, abstraction methods, and data collection practices
⦁ Identify workflow improvement opportunities and contribute to quality initiatives
⦁ Participate in cross-functional project teams focused on performance and quality improvement
⦁ Promote a data-driven culture of continuous improvement
⦁ Perform other related duties as assigned
What You Need
⦁ Bachelor’s degree in Healthcare Administration, Nursing, Public Health, or related field (or equivalent experience)
⦁ Minimum 2 years of experience in healthcare quality, medical record abstraction, or managed care
⦁ Working knowledge of HEDIS measures and abstraction methodology
⦁ Strong attention to detail and problem-solving skills
⦁ Proficiency with Microsoft Office and ability to learn multiple software systems
⦁ Strong verbal and written communication skills
⦁ Ability to work collaboratively and independently
Preferred
⦁ Experience with quality reporting, audits, or supplemental data submissions
⦁ Coding/clinical background or health information certification
Benefits
⦁ Competitive salary: $61,500–$89,500 (adjusted for location)
⦁ Medical, dental, vision, and pharmacy benefits
⦁ 403(b) with employer match
⦁ Paid time off and wellness resources
⦁ Career growth opportunities
Ready to help improve healthcare quality across the region? Apply today — positions fill fast.
Happy Hunting,
~Two Chicks…
by Terrance Ellis | Nov 20, 2025 | Uncategorized
Help drive clinical excellence and regulatory compliance across WellSense’s Medicaid and Medicare programs by leading quality improvement initiatives that directly impact member outcomes.
About WellSense Health Plan
WellSense is a nonprofit health plan serving more than 740,000 members across Massachusetts and New Hampshire. With more than 25 years of service, we provide accessible, high-quality health plans for Medicare, Medicaid, and Individual/Family members. Our mission is simple: deliver healthcare that works for every member, regardless of circumstance.
Schedule
• Full-time
• Fully remote
• Occasional travel for meetings or state-level quality sessions
• Cross-functional collaboration with clinical, operational, and analytics teams
What You’ll Do
• Serve as a subject matter expert for quality management across medical and behavioral health programs
• Lead the development and execution of corporate quality initiatives aligned with NCQA and state regulatory requirements
• Oversee quality improvement needs across all products in assigned regions (MA and/or NH)
• Chair workgroups and committees that track progress on corporate and regulatory quality initiatives
• Ensure compliance with contractual requirements from EOHHS, DHHS, EQRO, NCQA, and other regulatory bodies
• Develop detailed project plans, timelines, metrics, and outcome measures for performance improvement projects
• Facilitate large multidisciplinary teams to implement targeted quality interventions
• Prepare internal and external documentation, reports, and regulatory submissions
• Work closely with analytics teams to define data needs, analyze trends, and support quality decision-making
• Liaise with vendors to ensure accurate reporting and data integration
• Respond to regulatory inquiries and represent the plan at state quality meetings
• Identify improvement opportunities using internal and external data sources
• Manage day-to-day quality processes including document review, literature searches, and independent decision-making
• Ensure timely submission of all quality and regulatory deliverables
• Other duties as assigned
What You Need
• Bachelor’s degree in Nursing, Health Administration, or related field (or equivalent experience)
• Master’s degree in Social Work, Behavioral Health, Public Health, or related field preferred
• 5+ years of progressive experience in healthcare or managed care
• Strong knowledge of clinical quality management, quality improvement methodologies, and regulatory standards
• Experience working with Medicaid/Medicare populations preferred
• NCQA experience strongly preferred
• Project development or health policy experience a plus
• Lean Six Sigma or CPHQ training preferred
Benefits
• Competitive salary
• Full medical, dental, vision, and pharmacy coverage
• Flexible Spending Accounts
• Paid time off and wellness resources
• 403(b) retirement plan with employer match
• Career development and advancement opportunities
• Remote work with strong team support
If you’re ready to lead impactful quality initiatives and help shape better outcomes for vulnerable populations, this role is your next step.
Happy Hunting,
~Two Chicks…
by Terrance Ellis | Nov 20, 2025 | Uncategorized
Help strengthen relationships with healthcare providers and ensure accurate claims processing across WellSense’s Medicare, Medicaid, and commercial networks.
About WellSense Health Plan
WellSense is a nonprofit health plan serving more than 740,000 members across Massachusetts and New Hampshire. For over 25 years, we’ve delivered accessible, high-quality Medicare, Medicaid, and Individual/Family coverage. Our mission is to make healthcare work for everyone, regardless of circumstance.
Schedule
• Full-time
• Remote role with travel requirements
• Up to 50% travel to local communities for provider meetings
• Fast-paced workload with cross-department collaboration
Responsibilities
• Investigate, document, track, and help resolve provider claim issues
• Partner with Claims, Benefits, Enrollment, Audit, and Clinical Services to ensure timely and accurate claim payments
• Identify system changes impacting claims and collaborate internally to drive solutions
• Analyze claims processing trends and assist with issue quantification
• Run claim reports to support provider visits and outreach
• Strengthen relationships with physicians, clinicians, community health centers, and hospitals
• Serve as the primary contact for provider reimbursement questions and issue resolution
• Provide education to providers on WellSense products, policies, procedures, and operational processes
• Communicate Plan updates and ensure smooth information flow across departments
• Conduct outreach aligned with Plan initiatives
• Facilitate interdepartmental coordination to resolve complex provider issues
• Research provider data discrepancies in Onyx and Facets and request system updates when needed
• Support credentialing, servicing, and recruitment through report preparation
• Ensure compliance with NCQA and state agency requirements
• Other duties as assigned
• Maintain regular, reliable attendance
Requirements
Education
• Bachelor’s degree in Business Administration or related field, or equivalent experience
Experience
• 2 or more years in managed care or healthcare preferred
• Understanding of Medicare and Medicaid reimbursement methodologies
• Familiarity with provider coding and billing practices
• Experience with ICD-10, CPT/HCPCS, and claim form standards
Skills & Competencies
• Strong communication skills, written and verbal
• Proven ability to manage multiple priorities with strong follow-up habits
• High proficiency with Microsoft Office
• Strong organizational and independent problem-solving skills
• Ability to work collaboratively with teams and external partners
Additional Requirements
• Valid driver’s license and access to a vehicle
• Pre-employment background check
Benefits
• Competitive salary
• Full medical, dental, vision, and pharmacy coverage
• 403(b) retirement plan with employer match
• Paid time off and wellness support
• Flexible Spending Accounts
• Career development opportunities
• Full-time remote flexibility with community-based travel
If you’re a detail-oriented relationship builder who can navigate claims, coding, reimbursement, and provider engagement with confidence, this role is built for you.
Happy Hunting,
~Two Chicks…
by Terrance Ellis | Nov 20, 2025 | Uncategorized
Help ensure members receive timely, medically necessary care by reviewing inpatient, outpatient, and home health service requests. This role is essential to keeping patients safe, care efficient, and health outcomes strong.
About WellSense Health Plan
WellSense is a nonprofit health plan serving more than 740,000 members across Massachusetts and New Hampshire. For over 25 years, we’ve provided accessible, high-quality Medicare, Medicaid, and Individual/Family coverage designed to meet members where they are. Our mission is simple: deliver care that works for real people in real life.
Schedule
• Full-time
• Fully remote
• Occasional travel to Charlestown, MA for meetings or training
• After-hours call rotation required (evenings/nights/weekends)
What You’ll Do
• Review inpatient, outpatient, and home care service requests for medical necessity using InterQual® criteria, medical policy, and benefit guidelines
• Conduct pre-certification, concurrent, and retrospective utilization review
• Apply clinical judgement and evidence-based guidelines to determine coverage
• Document and communicate all review activities and outcomes clearly and accurately
• Refer cases to Physician Reviewers when medical necessity criteria aren’t met
• Ensure timely turnaround of all reviews based on Medicaid, ACA, CMS, and NCQA requirements
• Prepare and send determination letters to providers and members
• Support new utilization review nurses through guidance, coaching, and orientation
• Follow departmental workflows to ensure end-to-end case management compliance
• Participate in team meetings, continuing education, policy updates, and audit activities
• Identify workflow improvements and opportunities to strengthen communication
• Accurately document rate negotiation details for proper claims adjudication
• Identify and refer members to Care Management when appropriate
• Perform other related utilization management duties as assigned
What You Need
• Nursing degree or diploma; bachelor’s in nursing preferred
• Active, unrestricted RN license in state of residence (compact license preferred)
• 2 or more years of prior authorization/utilization review experience
• Experience with InterQual® guidelines and evidence-based review
• Managed care experience
• Knowledge of Medicare and Medicaid preferred
• Proficiency in Microsoft Office and clinical/claims systems
• Strong clinical judgement, communication skills, and attention to detail
• Ability to work independently in a remote environment while meeting regulatory deadlines
Benefits
• Competitive compensation
• Full medical, dental, vision, and pharmacy coverage
• 403(b) with employer match
• Flexible Spending Accounts
• Paid time off and wellness resources
• Career development and advancement opportunities
• Full-time remote flexibility
If you’re a detail-driven RN who thrives in fast-paced clinical decision environments, this role lets you use your expertise to directly impact patient care.
Happy Hunting,
~Two Chicks…
by Terrance Ellis | Nov 20, 2025 | Uncategorized
Support a mission-driven health plan by ensuring accurate HEDIS reporting, high-quality medical record abstraction, and regulatory compliance that directly impact member care and organizational performance.
About WellSense Health Plan
WellSense is a nonprofit health insurance plan serving more than 740,000 members across Massachusetts and New Hampshire. With over 25 years of experience, we provide Medicare, Medicaid, and Individual/Family plans built around accessibility, quality, and real-life support. Our team is dedicated to improving health outcomes and creating a better experience for every member.
Schedule
• Full-time
• Fully remote
• Standard business hours; some seasonal workload increases during HEDIS reporting cycles
Responsibilities
• Perform medical record abstraction and data entry for NCQA HEDIS® and related medical record–based audits
• Maintain an inter-rater reliability score of 90 percent or higher
• Conduct overreads to ensure accuracy and adherence to technical specifications
• Access, navigate, and abstract medical records across multiple EMR platforms (Epic, Cerner, Allscripts, etc.)
• Build collaborative relationships with provider partners to ensure timely, accurate record retrieval
• Use health plan systems to research member and claims data and validate service details
• Work with internal teams and provider offices to support a chart procurement rate of at least 95 percent
• Assist in annual training sessions on HEDIS measures, documentation practices, and data collection standards
• Identify and recommend improvements in abstraction workflows and quality performance
• Participate in cross-functional projects that support quality improvement and measure performance
• Promote a culture of continuous improvement and data-driven decision-making
• Perform additional quality-related duties as needed
Requirements
• Bachelor’s degree in healthcare administration, nursing, public health, or related field; or equivalent experience
• Minimum two years of experience in healthcare quality, medical record abstraction, or managed care
• Knowledge of HEDIS® measures and abstraction methodology
• Strong attention to detail with proven accuracy in data validation
• Proficiency in Microsoft Office and ability to learn multiple proprietary systems
• Effective written and verbal communication skills
• Ability to work collaboratively across departments and with external provider partners
Preferred
• Experience with quality reporting, regulatory audits, or supplemental data submissions
• Medical coding or clinical background
Benefits
• Competitive salary
• Medical, dental, vision, and pharmacy coverage
• 403(b) with employer match
• Flexible Spending Accounts
• Paid time off and wellness resources
• Career growth and advancement opportunities
• Full-time remote work
If you’re detail-oriented, thrive in a quality-driven environment, and want to help improve healthcare outcomes across multiple populations, this role fits you well.
Happy Hunting,
~Two Chicks…
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