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.

Our Investment in You:

• Full-time remote work
• Competitive salaries
• Excellent benefits

KEY FUNCTIONS/RESPONSIBILITIES:

• Provides clinical case review, consultation and oversight for all utilization management activities.
• Conducts review of prior authorizations, concurrent reviews and retrospective reviews that do not meet standard criteria and determines coverage.
• Works with the Medical Director of Utilization Management to identify appropriate us of InterQual criteria and Medical Policy.
• Works with the Medical Director to ensure consistent medical decision making for all physician reviewers, including the contracted physicians.
• Conducts clinical review of appeals and grievances.
• Develops and supports clinical initiatives to support department quality improvement and utilization management goals.
• Collaborates with hospital physicians, medical directors, primary care physicians and nurse case managers in daily activities and initiatives to improve the health of the population, the quality and experience of care our members receive, and lower the overall cost of care at the population level.
• Participates in and chairs clinical committees as assigned by the Medical Director of Utilization Management.
• Supports quality, and pharmacy committees and activities.
• Provides input to the strategic planning process for the Office of Clinical Affairs as requested.
• Represents the Chief Medical Officer in Massachusetts, New Hampshire and other locations as requested.

QUALIFICATIONS:

EDUCATION:

• Graduate as an MD/DO from an accredited college of allopathic or osteopathic medicine is required.

EXPERIENCE:

• 8-10+ years of experience post residency in direct patient care. Additional experience in utilization management, as a physician advisor, or in government role (e.g. state Medicaid agency or Medicare contractor) is desirable.

CERTIFICATION OR CONDITIONS OF EMPLOYMENT: 

• Board certification in recognized medical specialty of the American Board of Medical Specialties or the American Osteopathic Association Bureau of Osteopathic Specialists and meeting all requirements to maintain same board certification
• Current unrestricted licensure as an MD/DO in a US State or DC
• Current unrestricted licensure as an MD/DO in the Commonwealth of Massachusetts is preferred.
• Authorized to work in the United States

COMPETENCIES, SKILLS, AND ATTRIBUTES:

• Excellent demonstrated clinical skills and knowledge.
• Excellent written and verbal communication skills.
• Comprehensive knowledge of accrediting organizations such as NCQA.
• Comprehensive knowledge of InterQual protocols, HEDIS, and other quality measures.
• Knowledge of Medicare and state Medicaid regulations, guidelines, and standards.
• Proven leadership skills and relationship building.
• Knowledge of managed care principles and processes.
• Ability to work independently with intermittent supervision.
• Ability to work during core business hours of Eastern Time Zone
• Adhere to appropriate turn-around-times and deadlines while maintain results of high quality and reliability.

ABOUT WELLSENSE

WellSense Health Plan is a nonprofit health insurance company serving more than 440,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.

Required Skills Required Experience