Wellmark, Inc.
Medical Director Case Management & Quality
Wellmark, Inc., Des Moines, Iowa, United States, 50319
Company DescriptionWhy Wellmark : We are a mutual insurance company owned by our policy holders across Iowa and South Dakota, and we’ve built our reputation on over 80 years’ worth of trust. We are not motivated by profits. We are motivated by the well-being of our friends, family, and neighbors–our members. If you’re passionate about joining an organization working hard to put its members first, to provide best-in-class service, and one that is committed to sustainability and innovation, consider applying today!
Learn more about our unique benefit offerings here.
Want to know more? You can learn about life at Wellmark here.
Job DescriptionAbout the Opportunity:
As an experienced M.D. or D.O. in a managed care or healthcare administration setting, you will closely partner with our internal Case Management (CM) team on the appropriate coordination of care through evidence-based decision making. In addition, you will partner with the Health Services Quality team to design, develop and improve quality programs that support NCQA accreditation and quality case reviews. You will co-lead the Quality Improvement Committee (QIC) and chair the Credentialing Committee. In addition to CM and Quality program support, you will perform outpatient case reviews by applying your clinical expertise on Utilization Management (UM) cases that don’t meet nationally recognized UM criteria. You will concisely, effectively, and consistently synthesize clinical information to document a clear summary of a medically necessary determination. Join us on this continuous journey as we make health care better for our members!
About You:
You are decisive and have a strong ability to influence internally and externally by appropriately and effectively presenting evidence-based medicine to support a determination. Critical thinking, sound judgment, and decisiveness are key; however, you will be able to draw from your colleagues’ subject matter expertise from various departments, to help make evidence-based prior authorization decisions. You also use your influential and innovative nature to help design, develop and implement program improvements in partnership with internal leaders and teams. You are collaborative by nature and are energized by the opportunity to work in a highly integrated and matrixed culture. Managed care experience in a large commercial organization, such as at another Blue Cross & Blue Shield plan, is a plus.
If this sounds like you, apply to our Medical Director-Case Management & Quality opportunity today!
Iowa or South Dakota-based candidates preferred but open to remote for the right candidate.
QualificationsRequired Qualifications:
Graduate of an accredited medical school; M.D. or D.O. degree is required.
Active and unrestricted license to practice medicine in Iowa or Iowa Administrative Medical License is required within 3 months from date of hire AND must be licensed in the state in which you reside. While obtaining license, the incumbent will participate in training, provide operational guidance and advice, and participate in projects as assigned while licensure is pending approval.
Current Board Certification through the American Board of Medical Specialties (ABMS) or AOA (American Osteopathic Association).
Minimum 2-4 years of experience in managed care or administrative experience—e.g., clinical coordination, medical consulting, health plan, provider group, etc.
Ability to be flexible with work hours as needs require.
Strong analytical and critical thinking skills; makes sound evidence-based decisions.
Demonstrated commitment to service excellence (timeliness, accuracy, quality) and advocacy for member care.
Strong consulting and interpersonal skills. Demonstrates integrity and quickly builds rapport and establishes credibility.
Excellent verbal and written communication skills. Ability to communicate effectively and with clarity with internal and external audiences, and clinical peers, even when conveying difficult decisions and complex information.
Strong change management skills. Ability to create a clear view of future state and inspires others to advance the vision.
Ability to mentor and guide others and work within the teams. This includes sharing accountability, influencing without direct authority, and effectively listening to others.
Self-starter with strong organization and time management skills. Flexible with changing priorities.
Works well independently and collaborates as a member of a cross-functional team; ability to navigate in a dynamic corporate environment.
Strong technical acumen. Learns new systems and processes quickly (e.g. Microsoft Office, clinical platforms, etc.).
Preferred Qualifications:
Experience/knowledge with NCQA (National Committee for Quality Assurance) accreditation and improving HEDIS (Healthcare Effectiveness Data and Information Set) and CAHPS (Consumer Assessment of Healthcare Providers and Systems) results.
Additional InformationWhat you will do as a Medical Director for Case Management & Quality:
a. Develop an effective and collaborative working relationship with Wellmark’s Quality leadership as a trusted advisor in the design, development and implementation of Wellmark’s QM program to improve the health of our members.
b. Demonstrate evidence of impact in the design, development and implementation of QM programs in close collaboration with QM leadership.
c. Demonstrate strong understanding and knowledge base of Wellmark’s population profile.
d. Apply insights from population profile to identify potential actionable opportunities in close collaboration with Quality leadership to improve the health of Wellmark’s members.
e. Collaborate with Quality leadership to accept accountability for achieving key Quality deliverables including but not limited to NCQA accreditation standards and Wellmark’s population-based initiatives.
f. Chair Wellmark’s Credentialing Committee. Collaborate with legal and credentialing stakeholders to prepare for effective Credentialing Committee meetings. Demonstrate sound judgment in Credentialing decision-making and recommendations.
g. Develop an effective and collaborative relationship with Wellmark’s CM leaders as a trusted advisor in the design, development and implementation of Wellmark’s CM program to improve the health of our members.
h. Demonstrate evidence of impact in the design, development and implementation of CM programs in close collaboration with CM leadership.
i. Survey clinical literature and demonstrate critical thinking skills to identify emerging areas for CM interventions and collaborate with CM leadership to prioritize actionable initiatives.
j. Partner with Wellmark’s CM leadership to provide consultation on complex clinical cases to facilitate transition of care to the appropriate level.
k. Demonstrate effectiveness as physician leader and facilitator for regularly scheduled CM rounds with nurses.
l. Demonstrate ability to apply clinical experience in the care of patients in Outpatient (OP) setting to render medical necessity determinations for OP services. The foundation for Wellmark’s definition of medical necessity is Evidence-Based Medicine and evidence of sound clinical reasoning.
m. Concisely, effectively, and consistently synthesize clinical information to document a clear summary for the basis of medical necessity determinations. The documentation in the UM record will reflect the ability to act timely and decisively based on the clinical records that were submitted to support the medical necessity for the requested OP service.
n. Deep knowledge of, and proficiency in applying, Wellmark’s medical policies especially for commonly requested OP services.
o. Develop an effective and collaborative relationship with Wellmark’s UM leaders to continually improve the end-to-end UM process by providing ideas and feedback on improvement. Actively identify opportunities for process improvement or the need for new processes that are observed in the course of day-to-day work. Demonstrates openness to receiving and acting on constructive feedback.
p. Demonstrate ability to defend UM decisions internally and externally using evidence-based medicine, sound clinical reasoning, and critical thinking skills. Actively listen for relevant new information and compelling counterarguments. Revise decision when the fact basis requires it.
q. Demonstrate sound judgment by seeking consultation from leader on complex UM case reviews.
r. Effectively engage in peer-to-peer calls. Seek to understand new information that the provider may offer. Effectively and concisely uphold the UM decision or revise the UM decision based on new information when necessary.
s. Other duties as assigned.
This job requires a non-compete agreement.
Remote Eligible:
You will have the flexibility to work where you are most productive. This position is eligible to work fully remote. Depending on your location, you may still have the option to come into a Wellmark office if you wish to. Your leader may ask you to come into the office occasionally for specific meetings or other ‘moments that matter’ as well.
An Equal Opportunity Employer
The policy of Wellmark Blue Cross Blue Shield is to recruit, hire, train and promote individuals in all job classifications without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or any other characteristic protected by law.
Applicants requiring a reasonable accommodation due to a disability at any stage of the employment application process should contact us at
careers@wellmark.com
Please inform us if you meet the definition of a " Covered DoD official ".
#J-18808-Ljbffr
Learn more about our unique benefit offerings here.
Want to know more? You can learn about life at Wellmark here.
Job DescriptionAbout the Opportunity:
As an experienced M.D. or D.O. in a managed care or healthcare administration setting, you will closely partner with our internal Case Management (CM) team on the appropriate coordination of care through evidence-based decision making. In addition, you will partner with the Health Services Quality team to design, develop and improve quality programs that support NCQA accreditation and quality case reviews. You will co-lead the Quality Improvement Committee (QIC) and chair the Credentialing Committee. In addition to CM and Quality program support, you will perform outpatient case reviews by applying your clinical expertise on Utilization Management (UM) cases that don’t meet nationally recognized UM criteria. You will concisely, effectively, and consistently synthesize clinical information to document a clear summary of a medically necessary determination. Join us on this continuous journey as we make health care better for our members!
About You:
You are decisive and have a strong ability to influence internally and externally by appropriately and effectively presenting evidence-based medicine to support a determination. Critical thinking, sound judgment, and decisiveness are key; however, you will be able to draw from your colleagues’ subject matter expertise from various departments, to help make evidence-based prior authorization decisions. You also use your influential and innovative nature to help design, develop and implement program improvements in partnership with internal leaders and teams. You are collaborative by nature and are energized by the opportunity to work in a highly integrated and matrixed culture. Managed care experience in a large commercial organization, such as at another Blue Cross & Blue Shield plan, is a plus.
If this sounds like you, apply to our Medical Director-Case Management & Quality opportunity today!
Iowa or South Dakota-based candidates preferred but open to remote for the right candidate.
QualificationsRequired Qualifications:
Graduate of an accredited medical school; M.D. or D.O. degree is required.
Active and unrestricted license to practice medicine in Iowa or Iowa Administrative Medical License is required within 3 months from date of hire AND must be licensed in the state in which you reside. While obtaining license, the incumbent will participate in training, provide operational guidance and advice, and participate in projects as assigned while licensure is pending approval.
Current Board Certification through the American Board of Medical Specialties (ABMS) or AOA (American Osteopathic Association).
Minimum 2-4 years of experience in managed care or administrative experience—e.g., clinical coordination, medical consulting, health plan, provider group, etc.
Ability to be flexible with work hours as needs require.
Strong analytical and critical thinking skills; makes sound evidence-based decisions.
Demonstrated commitment to service excellence (timeliness, accuracy, quality) and advocacy for member care.
Strong consulting and interpersonal skills. Demonstrates integrity and quickly builds rapport and establishes credibility.
Excellent verbal and written communication skills. Ability to communicate effectively and with clarity with internal and external audiences, and clinical peers, even when conveying difficult decisions and complex information.
Strong change management skills. Ability to create a clear view of future state and inspires others to advance the vision.
Ability to mentor and guide others and work within the teams. This includes sharing accountability, influencing without direct authority, and effectively listening to others.
Self-starter with strong organization and time management skills. Flexible with changing priorities.
Works well independently and collaborates as a member of a cross-functional team; ability to navigate in a dynamic corporate environment.
Strong technical acumen. Learns new systems and processes quickly (e.g. Microsoft Office, clinical platforms, etc.).
Preferred Qualifications:
Experience/knowledge with NCQA (National Committee for Quality Assurance) accreditation and improving HEDIS (Healthcare Effectiveness Data and Information Set) and CAHPS (Consumer Assessment of Healthcare Providers and Systems) results.
Additional InformationWhat you will do as a Medical Director for Case Management & Quality:
a. Develop an effective and collaborative working relationship with Wellmark’s Quality leadership as a trusted advisor in the design, development and implementation of Wellmark’s QM program to improve the health of our members.
b. Demonstrate evidence of impact in the design, development and implementation of QM programs in close collaboration with QM leadership.
c. Demonstrate strong understanding and knowledge base of Wellmark’s population profile.
d. Apply insights from population profile to identify potential actionable opportunities in close collaboration with Quality leadership to improve the health of Wellmark’s members.
e. Collaborate with Quality leadership to accept accountability for achieving key Quality deliverables including but not limited to NCQA accreditation standards and Wellmark’s population-based initiatives.
f. Chair Wellmark’s Credentialing Committee. Collaborate with legal and credentialing stakeholders to prepare for effective Credentialing Committee meetings. Demonstrate sound judgment in Credentialing decision-making and recommendations.
g. Develop an effective and collaborative relationship with Wellmark’s CM leaders as a trusted advisor in the design, development and implementation of Wellmark’s CM program to improve the health of our members.
h. Demonstrate evidence of impact in the design, development and implementation of CM programs in close collaboration with CM leadership.
i. Survey clinical literature and demonstrate critical thinking skills to identify emerging areas for CM interventions and collaborate with CM leadership to prioritize actionable initiatives.
j. Partner with Wellmark’s CM leadership to provide consultation on complex clinical cases to facilitate transition of care to the appropriate level.
k. Demonstrate effectiveness as physician leader and facilitator for regularly scheduled CM rounds with nurses.
l. Demonstrate ability to apply clinical experience in the care of patients in Outpatient (OP) setting to render medical necessity determinations for OP services. The foundation for Wellmark’s definition of medical necessity is Evidence-Based Medicine and evidence of sound clinical reasoning.
m. Concisely, effectively, and consistently synthesize clinical information to document a clear summary for the basis of medical necessity determinations. The documentation in the UM record will reflect the ability to act timely and decisively based on the clinical records that were submitted to support the medical necessity for the requested OP service.
n. Deep knowledge of, and proficiency in applying, Wellmark’s medical policies especially for commonly requested OP services.
o. Develop an effective and collaborative relationship with Wellmark’s UM leaders to continually improve the end-to-end UM process by providing ideas and feedback on improvement. Actively identify opportunities for process improvement or the need for new processes that are observed in the course of day-to-day work. Demonstrates openness to receiving and acting on constructive feedback.
p. Demonstrate ability to defend UM decisions internally and externally using evidence-based medicine, sound clinical reasoning, and critical thinking skills. Actively listen for relevant new information and compelling counterarguments. Revise decision when the fact basis requires it.
q. Demonstrate sound judgment by seeking consultation from leader on complex UM case reviews.
r. Effectively engage in peer-to-peer calls. Seek to understand new information that the provider may offer. Effectively and concisely uphold the UM decision or revise the UM decision based on new information when necessary.
s. Other duties as assigned.
This job requires a non-compete agreement.
Remote Eligible:
You will have the flexibility to work where you are most productive. This position is eligible to work fully remote. Depending on your location, you may still have the option to come into a Wellmark office if you wish to. Your leader may ask you to come into the office occasionally for specific meetings or other ‘moments that matter’ as well.
An Equal Opportunity Employer
The policy of Wellmark Blue Cross Blue Shield is to recruit, hire, train and promote individuals in all job classifications without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or any other characteristic protected by law.
Applicants requiring a reasonable accommodation due to a disability at any stage of the employment application process should contact us at
careers@wellmark.com
Please inform us if you meet the definition of a " Covered DoD official ".
#J-18808-Ljbffr