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…
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…
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