Appeals and Grievances Quality Nurse

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 Grievances Quality Nurse audits appeals and grievances compliance, is responsible for regulatory reporting and universe preparation, regulatory audit support and presentation. The Appeals and Grievances Quality Nurse is responsible for clinical support of all clinical appeals and grievance activities. The Appeals and Grievances Quality Nurse collaborates with Member Appeals and Grievances Specialists, Program Coordinators, and other business partners across the organization to create and maintain quality policies and processes to assure program meets the agreed upon standards.

Our Investment in You:

·       Full-time remote work

·       Competitive salaries

·       Excellent benefits

Key Functions/Responsibilities:

• Evaluate accuracy of medical necessity appeals processing, decisions, and response notices
• Supports the grievance intake, investigation, and resolution processes and identifies trends and areas for improvement along with process improvement initiatives
• Audits timeless to ensure clinical appeals, administrative appeals, and grievances are resolved in a timely manner
• Assist with written correspondence to providers and members
• Collaborates with management to recommend coaching and provides ongoing feedback to staff based on trends and Quality findings either one-on-one, in a group, or in departmental settings.
• Conducts one-on-one coaching performance improvement.
• Assists with calibration sessions in accordance with department standards, to help ensure consistency and validation of audit parameters, KPIs, and requirements. 
• Provides suggestions on new process documentation and materials to support quality initiatives and to improve overall performance and compliance.
• Provides feedback to department leaders and managers.
• Identifies and documents defects, inconsistences and potential risk in workflow process and documentation.
• Maintains comprehensive understanding of appropriate departmental policies and procedures
• Maintains current knowledge of regulatory, contractual and accreditation requirements subject matter expert
• Other duties as assigned

Supervision Exercised:

·       None

Supervision Received:

• General supervision is received weekly

Qualifications:

Education Required:

• Registered Nurse
• Associate or Bachelor’s degree in Nursing or completion of a Diploma Nursing School
• 3+ years of experience in a managed care healthcare setting (various departments in a health insurance organization such as; appeals and grievances, customer service, claims experience or equivalent experience)

Education Preferred:

• BSN degree in Nursing

Experience Required:

• 2+ years of experience in a managed care healthcare setting
• 2+ years of Utilization Management (Helpful)
• Experience with payer specific medical guidelines and how to apply them in an appeal
• Experience using MCG and/or InterQual guidelines

Experience Preferred/Desirable:

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

Required Licensure, Certification or Conditions of Employment:

• Current Unrestricted RN license
• Successful completion of pre-employment background check

Competencies, Skills, and Attributes:

• Detail oriented, excellent verbal and written communication and organizational skills. 
• Ability to work in both team and independent settings at all levels of the organization.
• Exceptional customer service skills and experience working with diverse populations required.
• Knowledge of health care terminology desirable.
• Bi-lingual preferred.
• Demonstrated ability in facilitating cross-functional teams.
• Effective collaborative and proven process improvement skills.
• Strong analytical and problem-solving skills.
• Knowledge of analytics, metrics, and an ability to interpret data.
• Excellent de-escalation and dispute resolution skills

Working Conditions and Physical Effort:

• Regular and reliable attendance is an essential function of the position.
• 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 required

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