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…