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

Qualifications:

Education:

• 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

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