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…