Wellmark’s Medical Director translates their finely-tuned clinical expertise into Wellmark’s Medical Management department to improve outcomes and manage medical benefit costs through evidence-based medical reviews. Your broad clinical background and passion for patient care and sustainability of the health care system will be critical to your success in providing value to our providers and members. A highly collaborative sense of teamwork, good reputation with providers, and commitment to the health and well-being of Iowans and South Dakotans will be key to success in this role.
This position will require a signed non-compete agreement upon hire.
1) Within your first 30 days, you will develop a demonstrated understanding of the department including a deep dive into the workflows of fellow Medical Directors through job shadowing. You will also become familiar with relevant IT systems.
2) Within your first 60 days you will meet with stakeholders in various departments including but not limited to the following:
- Medical Policy: Oversees the research, development, implementation, and maintenance of medical policies and criteria; ensures medical policies and criteria are evidence-based and supported by medical literature.
- Appeals: Monitors, evaluates, measures, and reports compliance with ERISA, applicable laws, and regulatory compliance with respect to member and provider appeals.
- Utilization Management: Provides telephonic support for utilization management (e.g., pre-certifications, prior approvals, discharge planning, medical review) services to providers.
- Legal and Special Investigations: Provides legal guidance to Medical Management teams on a variety of topics and engages in the detection, investigation, and pursuit of allegations of health care insurance fraud or abuse.
- Network Innovation: Researches, develops, deploys, and monitors/measures performance of networkpilot payment strategies aligned with key health care organizations.
- Network Engagement: Acts as liaison between providers and Wellmark by building relationships with, educating, credentialing, and maintaining files for providers as well as addressing, analyzing, and resolving provider issues.
- Network Economics: Provides direction and support for the implementation and maintenance of provider payment methodology and policies.
- Pharmacy: Manages formulary and administers pharmacy claims, partnering with Medical Management teams to provide innovative solutions for reducing costs through clinical programs and utilization management.
You will also develop an understanding of the interactions of the Medical Review function with other areas of the business outside of Provider Relations and Health Management including Operations, Sales, Marketing, and Finance.
3) On a daily basis, you will receive escalated cases for review within Wellmark’s Care Management software. These cases require a keen clinical eye to provide valuable insight in the process of assessing medical necessity against evidence-based criteria. You will incorporate your clinical expertise into your review of these cases to create value for patients in a non-clinical environment.
4) The Care Management team works continuously to review current internal processes for areas of opportunity. As part of the Medical Director team you will be intimately involved in formal process improvement events and implementations. You will also be expected to contribute to continuous improvement efforts and play an active role in identifying opportunities to create a sustainable health care system in Iowa and South Dakota. You will use your knowledge of quality and process improvement methodologies to conceptualize ideas and seek out opportunities to document and improve processes within your own workflow and share learnings with members of your team.
5) You will review and analyze medical benefit expenses to help support Wellmark’s sustainability initiatives and the delivery of affordable premiums to members by examining medical trends, evaluating new technologies and procedures, and monitoring coding practices. You will incorporate clinical knowledge, continuous education, and business savvy to provide valuable insight into areas of opportunity and improvement for Wellmark and our member/provider communities. You will support the CMO in identifying various opportunities to leverage claims data to highlight practice pattern variation and recommend programs or interventions to eliminate waste and will actively participate in the development and deployment of provider payment methods that will support accountable care. You will also demonstrate rigor around evaluation and relative payment for new medical technology based on evidence, recommend new approaches, and exhibit influence within the provider community to deliver better care at a lower cost.
6) You will serve as a role model for Wellmark’s philosophy “It Starts With Us," a commitment to the health and wellness of our employees and our communities, which translates into a commitment to a healthy company and team culture. You will set an example for others in regards to work/life balance, wellness, and stress management, as well as in cultivating a dynamic, collaborative culture through interactivity within your own closely-knit Medical Director team and teams with which you interact within the larger organization. There are no lone-wolves here; our team of Medical Directors thrives in a highly collaborative environment of ongoing learning and knowledge transfer.
Wellmark's Core Competencies:
- Accountability: Owning and taking responsibility for one’s actions.
- Business Acumen: Understanding industry, market, financial and company specific operations.
- Collaboration and Communication: Working together; listen to other’s ideas; communicate accurately and concisely.
- Decision Making: Consider all facts and impacts when making decisions.
- Focus on the Customer: Consistently doing what is in the best interest of our customer. Leaving a positive impression on the customer by elevating their experience; making it simpler and educating to helping them understand.
Minimum Qualifications Required (all must be met to be considered)
M.D. or D.O. degree.
Active and unrestricted license to practice medicine in Iowa and/or South Dakota is required within 3 months from date of hire; must be licensed in the state in which you reside. In the meantime 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 approved by the American Board of Medical Specialties, American Osteopathic Association, or National Board of Physicians and Surgeons.
4+ years of clinical practice experience sufficient to enable candidate to make medical judgments as to appropriateness of care and medical necessity. A track record of accomplishment as a clinical leader demonstrating increasing responsibilities and expertise is essential.
Previous administrative medical experience—e.g., clinical coordination, medical consulting, medical director (health plan, provider group, hospital group), etc. Strong preference for prior medical director or similar experience at a health plan.
Understanding of the health care delivery system including, but not limited to, familiarity with outpatient facility and inpatient carebusiness models including reimbursement.
Industry knowledge, technical expertise, and strong relationship building skills to quickly build rapport, credibility, and collaborative partnerships with clinical peers, leaders, and stakeholders.
Demonstrated success leading and working within teams, including sharing accountability, influencing without direct authority, effectively listening to others, and effectively leading cross-functional teams.
Ability to make evidence-based decisions and review past history, benefit information, applicable policies, and other data to make sound, informed decisions in a timely manner.
General understanding of medical policy development, including the need as a health insurer to establish a balance within policy of the appropriate level or care for an individual and the overall population of covered members.
Proficiency with Microsoft Office applications – e.g., Word, Outlook.
Hiring Specifications Preferred
- Master's Degree in health care related field or business—e.g., MPH, MHA, MBA.
- Current Board Certification with completed residency training in a primary care specialty. The board certification must be approved by the American Board of Medical Specialties, American Osteopathic Association, or National Board of Physicians and Surgeons.
a. Customer Assist in acquisition of new customers by articulating the care management value proposition. Existing customers will be supported through management of the employee population and supporting client specific programs to manage the health of the employee population.
b. Care Management Ensure that the right care is provided in the right setting and the right time through various care management functions such as prior authorization, case management, pregnancy management, disease management and any other member facing programs.
c. Payment Innovation To ensure that the health care system is sustainable for our population and our customers, the MD will provide subject matter expertise in the refinement of our payment for quality programs and innovative reimbursement strategies that will promote improved care to our population of covered lives.
d. Policy Management As an integral supporting role to care management and claims payment programs, management of policy Medical, Utilization Management and Reimbursement will be a critical role for the MD to ensure that coverage and payment align with our customers needs. The MD will provide leadership and clinical expertise for policy development and implementation.
e. Network Management The MDs accountable in this area will ensure that our customers have a confidence level that our providers are qualified, that the quality of care is monitored and that any concerns are addressed and managed. The network of providers will also be supported by the Network Relations staff with assistance from the MDs. Since interaction with the network of care providers is essential, the Medical Director will improve provider relations in Iowa and South Dakota by collaborating and consulting with Practitioners and Providers periodically to share data, promote positive clinical outcomes and communicate Wellmark's policies, procedures and other collaborative efforts. Works closely with Wellmark's provider relations staff.
f. Special Investigations Provide clinical expertise to the special investigations unit to help with fraud and abuse investigations, provider interactions and legal proceedings to ensure payment for provider services is justified and appropriate.
g. Pharmacy Management Provide clinical expertise and guidance for pharmacy management to ensure that our formularies and management meets the needs of our customers by ensuring comprehensive and cost efficient medication coverage.
h. Claims Payment Assist in reimbursement claims payment policy as well as in claim review when clinical oversight is required for an optimal claim payment determination.
i. Medical trend Management Analyze medical benefit expenses efficiently in order to enable affordable premiums to members by examining trends, evaluating new technology/procedures and monitoring coding.
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Job ID 212582