Job summary
Job post source
This job is directly from WellSense Health Plan
Job overview
The Appeals and Grievance Specialist manages the resolution process of medical and pharmacy member appeals and complaints, ensuring compliance with regulations and standards.
Responsibilities and impact
Daily responsibilities include executing member appeals, coordinating grievance management, communicating with members and providers, and ensuring compliance with various regulatory requirements.
Compensation and benefits
The position offers full-time remote work, competitive salaries, and excellent benefits.
Experience and skills
A Bachelor’s degree in Health Care Administration or related field is required, along with 2 or more years of experience in a managed care organization and knowledge of Medicare processes.
Career development
Opportunities for professional growth may include involvement in appeals audits and the chance to implement improvement plans within the organization.
Work environment and culture
WellSense Health Plan values diversity and inclusion among its staff and members, fostering a supportive work environment.
Company information
WellSense Health Plan is a nonprofit health insurance company founded in 1997, serving over 740,000 members in Massachusetts and New Hampshire through various health plans.
Team overview
The job involves collaboration with internal departments and external vendors, indicating a team-oriented environment focused on compliance and quality improvement.
Job location and travel
The position is fully remote, allowing for flexibility in work location.
Application process
Qualified applicants can apply directly through the company's website, with no specific documentation or deadlines mentioned in the description.
Unique job features
The role is distinguished by its focus on compliance with multiple regulatory bodies and the opportunity to work with diverse populations.
Company overview
WellSense Health Plan is a non-profit managed care organization that provides health insurance plans to individuals and families, primarily through Medicaid and Medicare programs. They generate revenue by receiving payments from state and federal governments to manage healthcare services for their members. Founded in 1997 as Boston Medical Center HealthNet Plan, the company rebranded to WellSense Health Plan to reflect its broader mission of promoting wellness and making sense of healthcare complexities. They are known for their comprehensive coverage, community-focused initiatives, and commitment to improving health outcomes for underserved populations.
How to land this job
Tailor your resume to highlight your experience in managing appeals and grievances, emphasizing your understanding of CMS, MassHealth, and DHHS regulations, as these are crucial for the Appeals and Grievance Specialist role at WellSense Health Plan.
Showcase your skills in conflict resolution, project management, and communication, as these competencies are essential for effectively managing member complaints and grievances.
Apply through multiple channels, including WellSense Health Plan's corporate site and LinkedIn, to maximize your chances of being noticed by the hiring team.
Connect with professionals in the appeals and grievance division at WellSense Health Plan on LinkedIn to gain insights about the position; ice breakers could include discussing shared interests in healthcare compliance or asking about their experiences in the organization.
Optimize your resume for ATS by incorporating relevant keywords from the job description, such as 'appeals processing,' 'regulatory compliance,' and 'conflict resolution,' to enhance visibility during initial screenings.
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