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…