Impactful Appeals & Grievances 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 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