Appeals and Grievances Quality Nurse- BH WellSense Health Plan is a nonprofit health insurance company serving members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances. Apply now (https://jobs.silkroad.com/BMCHP/Careers/Apply/MultiForm/294556) 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 Nurseensures clinically appropriate and compliant appeals and grievances decisions through appeals and grievancesaudits,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 isresponsible 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:** + 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 **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 **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 Apply now (https://jobs.silkroad.com/BMCHP/Careers/Apply/MultiForm/294556) **Important info on employment offer scams:** According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not solicit individuals via text, we do not ask or require downloads of any applications, or “apps,” and applicant screenings, interviews and job offers are not conducted over text messages or social media platforms. You should never pay money for the promise of priority, interview or employment. We do not ask individuals to purchase equipment for, or prior to employment. To avoid becoming a victim of an employment offer scam, please followthese tips from the FTC (https://consumer.ftc.gov/consumer-alerts/2023/01/looking-job-scammers-might-be-looking-you?utm\_source=govdelivery) _._