Appeals and Grievance Specialist

WellSense Health Plan; Boston (MA); On-site; USD 49,000 - 71,000; Full time

Job summary

WellSense Health Plan is seeking an Appeals and Grievance Specialist to manage the resolution process of member appeals and grievances, ensuring compliance with regulatory standards. This role requires collaborating with multiple plan departments and external vendors, while maintaining documentation quality and reporting obligations.

The candidate should have a bachelor’s degree in health care administration or related field, 2+ years in managed care, and knowledge of CMS, MassHealth, and NCQA

Qualifications

• Bachelor’s degree in Health Care Administration or related field required.
• 2+ years’ experience in a managed care organization.
• Experience with Medicare medical/pharmacy appeals and grievances processes.
• Knowledge of CMS, MassHealth and DHHS contractual provisions and NCQA accreditation requirements desirable.

Responsibilities

• Manage resolution of member appeals across Plan departments and external vendors.
• Design appeal processing schedules and guidelines.
• Ensure CMS, MassHealth and DHHS regulatory compliance in line with applicable provisions.
• Coordinate grievance investigations with clinical staff and implement corrective actions when indicated.
• Prepare data, records, and reports to meet internal and external requirements.
• Ensure quality and organization of appeals documentation.
• Assist with reporting to CMS, MassHealth, DHHS, and the Connector Authority as needed.

Skills

Project management

Critical thinking

Microsoft Office

Communication

Teamwork

Customer service

Diversity awareness

Education

Bachelor’s degree in Health Care Administration

Job description

WellSense Health Plan is a nonprofit health insurance company serving more than 680,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded more than 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances.

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.

Key Functions/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

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

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