Remote Appeals & Grievance Specialist

Wellsense-Health-Plan; United States; Remote; USD 49,000 - 71,000; Full time

Benefits offered by this job

Full-time remote work

Competitive salaries

Excellent benefits

Job summary

WellSense Health Plan is seeking an Appeals and Grievance Specialist to manage the resolution of member appeals and complaints, while ensuring compliance with CMS, MassHealth, DHHS, and NCQA standards. The role supports CMS reporting and interdepartmental coordination.

The position offers full-time remote work with competitive compensation and extensive benefits, as part of WellSense’s commitment to member-centered care and regulatory excellence.

Qualifications

• Bachelor’s degree in Health Care Administration or related field required.
• 2+ years’ experience in a managed care organization required.
• Experience with Medicare medical and/or pharmacy prior authorization and appeals and grievances processes preferred.

Responsibilities

• Manages the resolution process of member appeals across multiple Plan departments and external vendors.
• Designs appeal processing schedules and guidelines per case and ensures compliance with CMS, MassHealth, DHHS directives.
• Acts as liaison between the Plan and external review bodies (IRE, QIO, Office of Medicaid’s Board of Hearing, NH State Fair Hearing).
• Prepares and issues appeal results letters and communicates with members and providers.

Skills

Project management

Critical thinking

Communication

Customer service

Teamwork

Education

Bachelor’s degree in Health Care Administration

Tools

Microsoft Office

Job description

WellSense Health Plan is seeking an Appeals and Grievance Specialist to manage the resolution of member appeals and complaints, while ensuring compliance with CMS, MassHealth, DHHS, and NCQA standards. The role supports CMS reporting and interdepartmental coordination.

The position offers full-time remote work with competitive compensation and extensive benefits, as part of WellSense’s commitment to member-centered care and regulatory excellence.