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 Inpatient UM Clinical Supervisor is responsible for the daily supervision and operations of the Inpatient Utilization Management clinical team. Assigns work, ensures compliance with policies and procedures and is the first point of contact for complex issues to ensure cost effective utilization management of inpatient admissions. In collaboration with the UM Clinical Trainer/QA, trains newly hired staff and ensures that ongoing training needs of incumbents are met. Under the direction of the Manager of Clinical UM, uses available data to prioritize inpatient reviews including admission reviews, level of care reviews and continued stay reviews in acute and post-acute inpatient settings. Works closely with, and may share specific business goals with other clinical and non-clinical supervisor within UM to ensure and support integrated UM processes. Our Investment in You: · Full-time remote work · Competitive salaries · Excellent benefits Key Functions/Responsibilities: - Monitors and evaluates the quality, timeliness, and accuracy of inpatient UM reviews and discharge planning. - Under the guidance of the UM Director and Managers, employs recommended techniques to foster team work and staff development. - Uses subject matter expertise as well as knowledge of the interconnection between UM, claims, and regulatory requirements to respond to complex and/or escalated inquiries. - Utilizes critical thinking skills to identify process issues and problems, and recommend and/or implement solutions. - Under the direction of the UM managers, develops and uses metrics and management reports to monitor staff productivity, efficiency, and quality. - May identify workflow and systems improvements to enhance UM’s ability to monitor, document, and improve key department performance indicators. - Ensures collaboration and integration with behavioral health care management, medical care management and social care management to ensure seamless transitions. - Collaborates with the Prior Authorization team and the care management team(s). - Participates in staff hiring, work allocation, training, performance management, including required documentation, as well as other supervisory functions under the guidance of the Manager of Clinical UM. - Assists with and participates in the planning, development, and implementation of department specific and cross functional projects. - Participates in maintaining accurate, consistent, updated department policies, procedures and workflows and related training materials. - In collaboration with the UM Clinical Trainer, is responsible for comprehensive orientation and ongoing training. - Uses the results of routine audits to monitor compliance with department standards and goals. - Provides high level of service and satisfaction to internal and external customers. - Responds to issues and concerns raised by staff and escalates to management as appropriate. - Other functions as required to support departmental activities. Supervision Exercised: - Directly supervises 5-15 staff. Supervision Received: - General supervision received weekly. Qualifications: Education Required: - Bachelor’s degree in Nursing or Associate’s degree with relevant work experience. Education Preferred: - Master’s degree in Nursing, related clinical field or Health Care Administration is preferred. - CCM or Managed Care Certification. Experience Required: - One year of prior supervisory experience. - Two or more years in a managed care organization. - Three years related RN experience in an acute care facility or health insurance environment. Experience Preferred/Desirable: - Experience with inpatient utilization management strongly preferred. - Experience with CCMS and/or Jiva, or other utilization management system. - Experience with InterQual or other nationally recognized medical necessity criteria. - Experience with Medicaid/Medicare recipients and community services. Required Licensure, Certification or Conditions of Employment: - Successful completion of pre-employment background check - Active unrestricted state licensure as a Registered Nurse in the Commonwealth of Massachusetts Competencies, Skills, and Attributes: - Demonstrated ability to lead a team. - Strong oral and written communication skills; ability to interact within all levels of the organization. - Demonstrated comfort with ambiguity and change. - Demonstrated ability to create positive energy with individuals and groups. - Demonstrated ability to take action in solving problems while exhibiting sound judgement. - Strong organizational and time management skills. - Ability to work in a fast paced environment and multi-task. - A strong working knowledge of Microsoft Office applications. - Strong analytical and problem-solving skills. - Knowledge of analytics, metrics, and the ability to interpret data. - Demonstrated ability to successfully plan, organize and manage projects. - Detail oriented, excellent proof reading and editing skills. - Knowledge of process improvement techniques. Working Conditions and Physical Effort: - Regular and reliable attendance is an essential function of the position. - 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. - Travel to regional offices is required. Compensation Range $88,500 - $128,500 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

Amaze Health is revolutionizing the healthcare landscape by empowering patients to take control of their healthcare journeys. Our mission is to simplify access to high-quality medical care while enhancing the patient experience. As a Nurse, you will be at the forefront of this mission, providing critical support and assessment to our patients in a timely and effective manner. We are seeking an experienced Registered Nurse (RN)  or Licensed Practice Nurse (LPN) with 5+ years of clinical experience in Family Medicine or Internal Medicine to support a growing weight management and metabolic health program. This role focuses on medical weight loss, GLP‑1 therapy management, and nutrition-focused patient education, working closely with providers to deliver evidence-based, patient-centered care. The ideal candidate is clinically strong, highly organized, comfortable with chronic disease management, and passionate about helping patients achieve sustainable weight loss and improved overall health. This is a fully remote position and requires strong assessment skills and the ability to collaborate closely with care teams. Key Responsibilities Clinical Care & Weight Management - Support patients in medical weight loss programs, including GLP-1 medications. - Conduct assessments, monitor progress, and follow-ups for weight management and chronic conditions. - Educate on medication use, side effects, and lifestyle integration. - Assist in care planning for obesity, diabetes, and related conditions. - Coordinate patient care across providers, pharmacies, and care teams.. GLP-1 & Medication Support - Provide support for GLP-1 medications (e.g., semaglutide, tirzepatide). - Triage patient inquiries about weight loss medications and monitor clinical indicators. - Ensure safe medication use and advocate for evidence-based practices. Nutrition & Lifestyle Education - Deliver nutrition and lifestyle counseling based on provider recommendations. - Encourage behavior change in diet and physical activity for long-term success. - Collaborate with providers and other health professionals as needed.

Job DetailsJob Location: Norwood, MA 02062Position Type: Full TimeSalary Range: $30.00 - $31.25 HourlyTravel Percentage: NoneCraving a New Adventure? Flex Your Clinical Skills Right from Your Couch! Are you a Registered Nurse (RN) seeking a role that challenges you, helps you grow, and lets you work from the comfort of your own home? MES has the perfect opportunity for you! We’re looking for a Clinical Quality Assurance Coordinator to join our team! In this role, you’ll be responsible for ensuring that Peer Review case reports meet the highest standards of quality, integrity, and compliance with client agreements, regulatory guidelines, and federal/state mandates. Why This Role Rocks: 100% Remote – Enjoy the flexibility of working from home! Impactful Work – You’ll play a key role in ensuring the quality and compliance of critical reports. Pick a Schedule That Works for You – Monday through Friday with rotating weekend shifts. Three days of 7:00am-3:30pm EST and two days of 12:00pm-8:30pm EST. Responsibilities include: Perform quality assurance review of peer review reports, correspondences, addendums or supplemental reviews. Ensure clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations. Ensure that all client instructions and specifications have been followed and that all questions have been addressed. Ensure each review is supported by clinical citations and references when applicable and verifies that all references cited are current and obtained from reputable medical journals and/or publications. Ensure the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards. Ensure the appropriate board specialty has reviewed the case in compliance with client specifications or state mandates and is documented accurately on the case report. Verify that the peer reviewer has attested to only the facts and that no evidence of reviewer conflict of interest exists. Ensure the provider credentials and signature are adhered to the final report. Identify any inconsistencies within the report and contacts the Peer Reviewer to obtain clarification, modification or correction as needed. Assist in resolution of client complaints and quality assurance issues as needed. Ensure all federal ERISA and state mandates are adhered to at all times. Provide insight and direction to management on consultant quality, availability and compliance with all company policies and procedures and client specifications. Promote effective and efficient utilization of company resources. Participate in various educational and or training activities as required. Perform other duties as assigned. If you’re a motivated, energetic RN ready to take on an exciting new challenge, we want you on our team! At MES, we offer a dynamic environment where your skills will shine. QualificationsHigh school diploma or equivalent required. A minimum of two years clinical or related field experience; or equivalent combination of education and experience. Knowledge of the insurance industry preferably claims management relative to one or more of the following categories: workers' compensation, no-fault, liability, and/or disability. Must have strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values. Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers and decimals; Ability to compute rates and percentages. Must be a qualified typist with a minimum of 40 W.P.M Must be able to operate a general computer, fax, copier, scanner, and telephone. Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet. Must possess excellent skills in English usage, grammar, punctuation and style. Ability to follow instructions and respond to upper managements’ directions accurately. Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met. Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed. Must be able to work independently, prioritize work activities and use time efficiently. Must be able to maintain confidentiality. MES Solutions is a premier provider of independent medical examination and peer review services to the insurance, corporate, legal, and government sectors. Members of our credentialed medical panel conduct physical examinations or medical record reviews, delivering reports that assist clients in the resolution of automotive, disability, liability, and workers' compensation claims. MES has been providing services nationally since 1978 in accordance with the industry's highest standards of operating excellence and regulatory compliance. MES offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k. Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.

Clinical Outreach Specialist | PHIL Location: Remote role About the Company: Founded in 2015, PHIL is a San Francisco-based, Series D health-tech startup that is building a platform that interfaces between doctors, pharmacies, and patients to streamline the process of patients receiving their specialty pharmaceutical prescriptions. Our mission is to ensure consistent, reliable, and affordable access to prescribed medicines for our patient community. Partnering with pharmaceutical manufacturers, PHIL offers digital patient access services to improve health outcomes for patients across the U.S. by delivering affordable and timely access to higher-cost specialty therapeutics. Headquartered in Scottsdale, AZ with operational hubs in Scottsdale and Columbus, OH, the company currently employs over 120 individuals and expects to double its employee base in the coming year. The team at PHIL is a group of like-minded individuals from varying backgrounds, passionate about creating a new and innovative healthcare platform that is focused on the prescriber and patient experience. Ready to join our team of mission-driven, analytical, and passionate people? Keep reading! Position Overview The Clinical Outreach Specialist role will help drive PHIL’s engagement with the Health Care Providers (HCPs) who prescribe medicines to our patients. You will be a part of a dedicated team focused on expanding PHIL’s HCP relationships by directly engaging with HCPs and their offices – from developing rapport with office staff and understanding office protocols to educating them on PHIL processes to introducing them to new product launches on the PHIL platform. A successful candidate will be able to maintain a “customer service” mindset and approach in all interactions with physicians and office staff. You will be able to understand PHIL’s internal processes and clearly explain them to offices. You will be responsible for responding to office feedback, identifying opportunities for improvements, and working with internal teams to develop solutions. You will be able to readily learn new information and adjust daily activities as we implement new office engagement strategies and introduce new programs. Key Responsibilities - Provide excellent customer service by communicating effectively with prescribers and office staff via phone call and digital message formats - Provide effective cold call outreach to build office relationships and maintain ongoing rapport with offices and physicians - Understand and explain end-to-end prescription lifecycle to provider offices with appropriate level of detail - Understand and explain program-level rules, expected patient copays, and expected processing timelines and be able to accurately and clearly explain to prescribers and office staff - Provide best practices to pursue coverage for patients via the prior authorization process - Triage, resolve, and respond to order-related escalations or one-off requests - De-escalate providers by using active listening, determining the correct root cause, and reassuring HCPs about solutions and our ability to serve - Recommend solutions for internal teams at PHIL based on feedback to prevent errors and improve Health Care Partners experience - Understand needs of HCPs based on their patient population and behavior and recommend effective solutions to increase medication access for patients Ideal Candidate Background and Competencies - Prior experience working in physician offices or other healthcare delivery environments - Prior experience with electronic health record (EHR) platforms - Has a working understanding of medical prescription processing, including electronic prescription submission and prior authorization processing - Experience in making cold outreach calls - Strong interpersonal skills to engage with offices and develop good working rapport with office staff and physicians alike - Willingness to learn and understand operational workflows in order to quickly determine root causes and to help suggest solutions - Can pinpoint and diagnose feedback from HCPs and turn it into meaningful and actionable insights to drive improvements across the organization - Can communicate professionally and courteously to reduce HCP churn and improve patient outcomes - Solution-oriented approach to find sustainable solutions for our HCPs - Excellent written and oral (phone) communication skills - Team player who wants to help build up others - Ability to be flexible in daily work activities as strategies and program needs change Benefits: - Ground floor opportunity with one of the fastest-growing startups in health-tech - Fully remote working environment in these states: AZ, CA, CO, FL, GA, IA, ID, IL, IN, MA, MI, MO, NC, NH, NJ, NY, OH, OK, OR, PA, SC, TN, TX, UT, VA, WA, WI, WV (occasional travel may be required) - Competitive compensation (commensurate with experience) - Full benefits (medical, dental, vision) - 401(k) PHIL Inc. is an equal-opportunity employer.