Appeals and Grievance Specialist

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.
Job Summary
The Appeals and Grievance Specialist is responsible for managing the resolution process of medical and pharmacy member appeals and/or member generated complaints/grievances, and ensuring compliance with contractual obligations, regulatory requirements and accreditation standards.
Our Investment In You
Full-time remote work
Competitive salaries
Excellent benefits
Key Functions/Responsibilities
Appeals Responsibilities:
Executes member appeals across multiple departments within the Plan and with representatives from external vendors
Determines and designs appeal processing schedule and guidelines on case-by-case basis
Ensures compliance with CMS, MassHealth and DHHS directives in a manner that is consistent with CMS’, MassHealth’s and DHHS’s interpretation of statute, regulation and contractual provisions
Acts as a liaison between the Plan and the IRE, QIO, Office of Medicaid’s Board of Hearing and the NH State Fair Hearing
Also ensures compliance with Qualified Health Plans, Commercial/Employer Choice contract regulations, and acts as a liaison between the Plan and the Department of Public Health, Health Policy Commission
Ensures compliance with NCQA accreditation standards for appeals processing and documentation
Participates and provides recommendations in appeals audits to monitor compliance and identify opportunities for improvement both within the team and within the organization
Initiates, drafts and issues appeal results determination letters to members and external vendors
Communicates with members, providers and internal and external medical personnel to discuss appeal results when questions arise
Responsible for the preparation, research of data and records as well as all associated reports required to meet internal and external requirements
Ensures quality and organization of appeals documentation
Assists with reporting to CMS, MassHealth, DHHS and the Connector Authority, as needed
Complaint/Grievance Responsibilities
Coordinates management of member complaints and grievances with other internal departments and representatives from external vendors, and ensures workflow continuity within the Plan
Works with clinical staff to investigate grievances related to quality of care received throughout the network and once reviewed, follow-up under the guidance of clinical staff to implement corrective action plans when indicated
Responds to, documents, investigates and facilitates the resolution of member complaints and grievances, including the writing, review, and approval of resolution letters
Ensures compliance with regulatory interpretation of statute, regulations and contractual provisions
Ensures the quality and organization of complaint and grievance documentation
Identifies and communicates trends
Works with other departments to create and implement improvement plans
Education
Qualifications:
A Bachelor’s degree in Health Care Administration, related field or, an equivalent combination of education, training and experience is required
Experience
2 or more years’ experience working in a managed care organization required
Experience with Medicare medical and/or pharmacy prior authorization and appeals and grievances processes required
Knowledge and experience in conflict resolution highly preferred
Comprehensive knowledge of CMS, MassHealth and DHHS contractual provisions and NCQA accreditation requirements highly desirable
Competencies, Skills, And Attributes
Demonstrated ability to successfully plan, organize, and manage projects within a managed care organization
Critical thinking and independent decision making skills, essential
Strong working knowledge of Microsoft Office products, required
Detail oriented, excellent verbal and written communication skills, essential
Ability to work in both team and independent settings at all levels of the organization
Good customer service skills, essential
Experience working with diverse populations, preferred
Knowledge of health care terminology, helpful
Bi-lingual preferred
Compensation Range
$48,500- $70,500
This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.
Note: This range is based on Boston-area data, and is subject to modification based on geographic location.
About WellSense
WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.
Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

Work arrangement
Yes