Remote Appeals & Grievance Specialist

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

Benefits offered by this job

Remote work

Competitive salary

Excellent benefits

Job summary

WellSense Health Plan is seeking an Appeals and Grievance Specialist to manage the resolution of medical and pharmacy member appeals and complaints, ensuring compliance with CMS, MassHealth, and NCQA standards. This full-time remote role offers competitive salaries and excellent benefits.

Responsibilities include coordinating with internal departments and external vendors, drafting determination letters, and ensuring timely, accurate documentation and reporting to regulators.

Qualifications

• Bachelor's degree in Health Care Administration or equivalent combination of education and experience.
• 2+ years in a managed care organization or similar setting.
• Experience with Medicare/Pharmacy prior authorization and appeals/grievances preferred.

Responsibilities

• Manage resolution of member appeals across multiple departments and external vendors.
• Ensure compliance with CMS, MassHealth, DHHS directives and NCQA accreditation.
• Draft and issue appeal results letters; communicate outcomes to members and providers.
• Coordinate with internal departments to investigate grievances and support corrective actions.
• Maintain documentation and reporting for CMS, MassHealth, DHHS and regulators.

Skills

Project management

Critical thinking

MS Office

Communication

Customer service

Bilingual preferred

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 medical and pharmacy member appeals and complaints, ensuring compliance with CMS, MassHealth, and NCQA standards. This full-time remote role offers competitive salaries and excellent benefits.

Responsibilities include coordinating with internal departments and external vendors, drafting determination letters, and ensuring timely, accurate documentation and reporting to regulators.