Appeals and Grievances Quality Nurse- BH

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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 BH Quality Nurse ensures clinically appropriate and compliant appeals and grievances decisions through appeals and grievances audits, responsibility for regulatory reporting and universe preparation, and regulatory audit support and presentation. The Appeals and Grievances BH Quality Nurse focuses on improving the quality of care for members with behavioral health and substance use needs. The Appeals and Grievances BH Quality Nurse is responsible for clinical support of all clinical appeals and grievance activities. The Appeals and Grievances BH Quality Nurse collaborates with other Appeals and Grievances Quality Nurses, Member Appeals and Grievances Specialists, Program Coordinators, as well as 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:

Member Appeals and Grievances

• 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, particularly in BH/SU topics
• 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)
• Strong foundation in mental health conditions, psychopharmacology, crisis intervention, and relevant regulations
• Ability to communicate and coordinate with internal and external partners to provide effective and cost-efficient care

Education Preferred:

·       BSN degree in Nursing

·       American Nurses Credentialing Center (ANCC) Certification in Psychiatric-Mental Health 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
• Knowledge of addiction medicine and treatment protocols.
• Knowledge of psychiatric medicine and treatment protocols.
• Working knowledge of Mental Health Laws and practice standards.
• Working knowledge of interdisciplinary treatment team process, behavioral health programming and daily nursing functions for inpatient and outpatient behavioral health units.
• Working knowledge of the continuum of care for behavioral health care.

Experience Preferred/Desirable:

• Previous psychiatric nursing experience preferred, in an inpatient or outpatient setting and/or previous experience in a substance use treatment facility
• 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

Compensation Range 

$69,500- $ 100,500

This range offers an estimate based on the minimum job qualifications.  However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer.  This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.  

Note: This range is based on Boston-area data, and is subject to modification based on geographic location. 

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

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