by Terrance Ellis | Nov 20, 2025 | Uncategorized
Help Medicare and Medicaid members access the medications they need by processing prior authorizations, resolving pharmacy-related issues, and supporting daily pharmacy operations. This role keeps care moving for thousands of individuals who rely on WellSense for timely, accurate coverage decisions.
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 offered Medicare, Medicaid, and Individual/Family plans built around accessibility, quality, and real-life support. Our mission is to provide healthcare coverage that truly works for every member, no matter their circumstances.
Schedule
• Full-time
• Fully remote
• Standard business hours with some flexibility based on operational needs
What You’ll Do
• Receive, process, and review prior authorization requests via fax, phone, or electronic systems
• Apply clinical policy criteria accurately to determine authorization outcomes
• Review member eligibility, claim history, and pharmacy program information using PBM software
• Interpret pharmacy and medical data and enter information according to regulatory and NCQA standards
• Communicate determinations to members and providers by phone, fax, and written notifications
• Analyze and resolve issues related to formulary administration and pharmacy benefit operations
• Provide pharmacy-related customer service to internal teams and external providers
• Process real-time claim authorizations using PBM adjudication systems
• Support implementation of new clinical pharmacy programs
• Serve as a resource for Member Services and internal departments regarding pharmacy benefits, policies, and plan designs
• Perform other operational duties as needed
What You Need
• High school diploma or equivalent
• Two or more years of experience in a pharmacy or professional setting
• Prior customer service experience
• Strong organizational and problem-solving skills
• Excellent written and verbal communication abilities
• Ability to multitask, manage competing priorities, and handle detailed data entry
• Strong interpersonal skills and comfort assisting members and providers over the phone
Preferred
• Associate or Bachelor’s degree
• Previous managed care experience
Benefits
• Competitive compensation
• Medical, dental, vision, and pharmacy benefits
• 403(b) with employer match
• Paid time off and wellness resources
• Career growth and advancement opportunities
• Flexible Spending Accounts and merit increases
• Fully remote work environment
If you want a remote pharmacy role where your work directly impacts member access to care, this is a strong fit.
Happy Hunting,
~Two Chicks…
by Terrance Ellis | Nov 20, 2025 | Uncategorized
Support Medicare Part D members by coordinating pharmacy operations, resolving escalated issues, and ensuring compliance with CMS regulations that protect safe, timely medication access.
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 Medicare, Medicaid, and Individual/Family plans that meet members where they are. Our mission is simple: provide high-quality coverage that works for real people in real life.
Schedule
• Full-time
• Fully remote
• Standard business hours with occasional priority tasks based on operational needs
What You’ll Do
• Support Medicare Part D formulary management, compliance, reporting, and oversight
• Review and resolve daily claim reject reports and transition monitoring items
• Draft and send provider communications to support member medication access
• Maintain expert-level understanding of CMS Part D regulations
• Partner with internal teams (Appeals & Grievances, Member Services, Care Management) to share information and resolve issues
• Coordinate escalated member, pharmacy, and provider inquiries with the PBM and related vendors
• Monitor prior authorization requests and coordinate routing for clinical review, PBM processing, or appeals
• Support clinical pharmacy staff and utilization management operations
• Assist in oversight of the PBM by reviewing formulary materials, testing claims adjudication, verifying reporting accuracy, and joining weekly account calls
• Provide support for STARS Quality program activities
• Educate other departments on pharmacy processes as needed
What You Need
• High school diploma or GED
• Two or more years of experience in a professional setting
• Two or more years of pharmacy experience (required)
• Strong communication skills (written and verbal)
• Ability to make sound decisions using established guidelines
• Ability to work effectively on a team
• Strong organizational skills and ability to multitask
• Proficiency with Microsoft Office
• Successful completion of a pre-employment background check
Preferred
• Associate degree or equivalent training
• Customer service experience
• Managed care experience within a Medicare plan
Benefits
• Competitive hourly rate ($20.19 – $28.13, based on experience and location)
• Medical, dental, vision, and pharmacy benefits
• 403(b) with employer match
• Flexible Spending Accounts
• Merit increases and advancement opportunities
• Paid time off
• Wellness and family-support resources
If you want a role where your work directly improves medication access and member safety, this is it.
Happy Hunting,
~Two Chicks…
by Terrance Ellis | Nov 20, 2025 | Uncategorized
Help members receive the right care at the right time by reviewing inpatient cases, supporting transitions of care, and ensuring clinical decisions meet evidence-based standards.
About WellSense Health Plan
WellSense is a nonprofit health insurance plan serving more than 740,000 members across Massachusetts and New Hampshire. With 25+ years of experience in Medicare, Medicaid, and Individual/Family coverage, we’re committed to providing health plans that truly work for our members, no matter their circumstances.
Schedule
• Full-time, remote role
• After-hours call may be required (evenings/nights/weekends)
• Occasional travel to Charlestown, MA for team meetings or training
Responsibilities
• Conduct concurrent, prospective, and retrospective inpatient utilization reviews using InterQual® and Medical Policy
• Evaluate medical necessity, clinical appropriateness, and contractual alignment of inpatient services
• Gather clinical information from EMRs to support timely decision-making
• Document, track, and communicate all utilization review activities and outcomes
• Refer cases to Physician Reviewers when guidelines aren’t met or aren’t available
• Ensure compliance with Medicaid, ACA, CMS, and NCQA timelines and regulatory requirements
• Identify delays in care and collaborate with providers and Medical Directors to resolve barriers
• Send timely authorization, denial, and determination letters to members and providers
• Participate in discharge planning discussions with facility teams to ensure smooth transitions of care
• Provide coaching and support to other utilization review nurses and assist with new-hire orientation
• Identify opportunities for process improvement and communication enhancements
• Support audit preparation and participate in audit activities as needed
• Accurately document rate negotiation details for claims adjudication
• Refer members to Care Management when appropriate
• Maintain compliance with all departmental policies, workflows, and documentation standards
• Attend team meetings, training sessions, and continuing education
Requirements
• Active, unrestricted RN license in state of residence
• Nursing degree or diploma required
• 2+ years of utilization review experience using evidence-based criteria (InterQual required)
• Managed care experience
• Experience with discharge planning
• Ability to work independently in a remote environment
• Strong clinical judgment, critical thinking, and problem-solving ability
• Excellent verbal and written communication skills
• Strong interpersonal skills for working with providers, facilities, and internal teams
• Proficiency with Microsoft Office and clinical data systems
• Must adhere to WellSense’s Telecommuter Policy
• Successful completion of pre-employment background check
Preferred
• Bachelor’s degree in Nursing
• RN license in MA, NH, or compact license
• Knowledge of Medicare and Medicaid regulations
Benefits
• Competitive salary range: Based on experience and geographic market
• Full medical, dental, vision, and pharmacy coverage
• 403(b) with employer match
• Flexible Spending Accounts
• Merit increases and advancement opportunities
• Paid time off
• Wellness and family-support resources
Be part of a mission-driven team ensuring that members receive clinically appropriate, timely, and cost-effective inpatient care.
Happy Hunting,
~Two Chicks…
by Terrance Ellis | Nov 20, 2025 | Uncategorized
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…
by Terrance Ellis | Nov 20, 2025 | Uncategorized
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…
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