Appeals and Grievance Specialist

Job Title: Appeals and Grievance Specialist

WellSense Health Plan is seeking a dedicated Appeals and Grievance Specialist to join our team. This remote position offers competitive salaries, excellent benefits, and the opportunity to work for a nonprofit health insurance company with a 25-year history of providing quality health plans.

Job Summary

The Appeals and Grievance Specialist will be responsible for managing the resolution process of medical and pharmacy member appeals and complaints/grievances. This includes ensuring compliance with contractual obligations, regulatory requirements, and accreditation standards.

Key Functions/Responsibilities

As the Appeals and Grievance Specialist, you will be responsible for executing member appeals, determining appeal processing schedules, and ensuring compliance with regulatory directives. You will also be involved in managing member complaints and grievances, coordinating with internal departments and external vendors.

Qualifications

To be successful in this role, you must have a Bachelor’s degree in Health Care Administration or a related field, as well as 2 or more years of experience working in a managed care organization. Knowledge of CMS, MassHealth, and DHHS contractual provisions is highly desirable, along with strong project management and communication skills.

About WellSense

WellSense Health Plan is committed to providing high-quality health plans and services to over 740,000 members in Massachusetts and New Hampshire. We value diversity and inclusion in our staff and members, and we are dedicated to creating a supportive work environment for all employees.

Apply Now

If you are looking for a rewarding career opportunity in the healthcare industry, consider applying for the Appeals and Grievance Specialist position at WellSense Health Plan. Join our team and make a difference in the lives of our members.

Apply Now