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…