Senior Clinical Specialist – Appeals and Grievances (Remote Opportunity)

Join WellSense Health Plan, a leading non-profit health insurance provider with a 25-year legacy of member-focused care, as a Senior Clinical Specialist specializing in Appeals and Grievances! This dynamic and impactful role offers a unique opportunity to leverage your clinical expertise and analytical skills to advocate for our members and ensure equitable access to care. We are seeking a highly motivated and detail-oriented nursing professional to join our growing team in a fully remote capacity, providing crucial clinical support throughout the appeals and grievance process.

At WellSense, we are committed to providing exceptional healthcare solutions to over 740,000 members across Massachusetts and New Hampshire, serving diverse populations through Medicare, Individual & Family, and Medicaid plans. We foster a collaborative and supportive work environment where your contributions directly impact the well-being of our members. This is an exciting time to be a part of WellSense, and we are looking for a dedicated individual to help us continue to deliver on our mission.

Job Summary

The Senior Clinical Specialist – Appeals and Grievances plays a pivotal role in the resolution of complex member appeals and grievances. You will be responsible for the comprehensive clinical review of appeals, meticulously analyzing member information, medical records (including prospective, inpatient, and retrospective reviews), and relevant documentation to determine the clinical validity of denied services. Working in close collaboration with the Appeals and Grievances Department staff and Medical Directors, you will provide critical clinical insights, recommendations, and support to ensure timely and accurate resolution of cases. This position requires a strong understanding of medical necessity criteria, payer guidelines, and regulatory requirements, coupled with exceptional analytical, communication, and problem-solving skills. You will be a key advocate for our members, ensuring their voices are heard and their healthcare needs are met.

Our Investment in You

• Fully Remote Work Environment: Enjoy the flexibility and convenience of working from home.
• Competitive Salary: We offer a competitive salary commensurate with experience and qualifications.
• Excellent Benefits Package: Comprehensive health, dental, vision, and other benefits are provided.
• Professional Development Opportunities: We invest in our employees' growth through ongoing training and development.
• Meaningful Work: Contribute to a mission-driven organization dedicated to improving the health and well-being of our members.

Key Functions/Responsibilities

• Member Appeals and Grievances:
  • Thoroughly investigate medical necessity appeals, conducting comprehensive reviews of prospective, inpatient, and retrospective medical records of denied services.
  • Provide critical support to the grievance intake, investigation, and resolution processes, proactively identifying trends and areas for process improvement.
  • Ensure all clinical appeals and grievances are addressed in a timely and efficient manner, adhering to established timelines and quality standards.
  • Prepare detailed clinical reviews and provide ongoing monitoring of cases involving medical decisions, quality of services, and patient care.
  • Draft clear and concise written correspondence to providers and members, addressing inquiries and providing updates.
  • Prepare comprehensive case reviews for the Medical Director when medical necessity criteria are not met, incorporating additional clinical information.
  • Prepare and coordinate case reviews for appeals requiring external review, ensuring all necessary information and questions are included in the external review request.
  • Act as a liaison with the peer review vendor, providing clinical consultations for member appeals and serving as a key intermediary between the vendor and Plan medical directors regarding case findings.
  • Present well-supported recommendations based on thorough clinical review, established criteria, and organizational policies.
  • Ensure strict compliance with HIPAA and other relevant privacy and security regulations to protect patient confidentiality.
  • Proactively contact and educate members and guarantors regarding the necessary steps to resolve outstanding appeals.
  • Maintain a strong understanding of contractual, regulatory, and accreditation requirements.
  • Serve as a subject matter expert, staying current on regulatory, contractual, and accreditation requirements.
  • Act as a liaison with the Quality department, forwarding potential quality of care grievances for thorough investigation.
  • Perform other duties as assigned to support the department's objectives.

Supervision Exercised

None

Supervision Received

General supervision is received weekly.

Qualifications

Education Required

• Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) or Registered Nurse (RN)
• Associate's or Bachelor's degree in Nursing or completion of a Diploma Nursing School

Education Preferred

• Bachelor of Science in Nursing (BSN) degree in Nursing

Experience Required

• Minimum of 2 years of experience in a managed care healthcare setting.
• Minimum of 2 years of experience in Utilization Management (strongly preferred).
• Proven experience with payer-specific medical guidelines and the ability to effectively apply them in the appeals process.
• Demonstrated experience using MCG and/or InterQual guidelines.

Experience Preferred/Desirable

• Comprehensive knowledge of Medicaid and Medicare contractual provisions and NQCA accreditation requirements is highly desirable.

Required License, Certification or Conditions of Employment

• Current, unrestricted LPN, LVN, and/or RN license.
• Successful completion of a pre-employment background check.

Competencies, Skills, and Attributes

• Highly detail-oriented with excellent verbal and written communication and organizational skills.
• Ability to effectively work both independently and collaboratively within team settings at all levels of the organization.
• Exceptional customer service skills and proven experience working with diverse populations.
• Strong knowledge of healthcare terminology is desirable.
• Bilingual proficiency is preferred.
• Demonstrated ability to facilitate cross-functional teams.
• Effective collaborative and proven process improvement skills.
• Strong analytical and problem-solving skills with the ability to interpret data and metrics.
• Excellent de-escalation and dispute resolution skills.

Working Conditions and Physical Effort

• Regular and reliable attendance is an essential function of the position.
• Work is typically performed in a fast-paced office environment.
• Work is normally performed in a typical interior/office work environment.
• No or very limited physical effort required. No or very limited exposure to physical risk.
• Occasional travel may be required.

About WellSense

WellSense Health Plan is a non-profit health insurance company serving over 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, we are dedicated to providing high-quality health plans and services that prioritize the well-being of our members, regardless of their circumstances. Apply now and be a part of our dedicated team! For more career opportunities, please visit Apply To This Job.

Ready for an Easy Start?

This is a rewarding role offering a supportive environment and the opportunity to make a real difference in the lives of our members. If you are a reliable and eager learner, we encourage you to apply today!