Vice President of Operations and Medical Review ( Medicare )


Madison, WI

Industry: Healthcare


8 - 10 years

Posted 73 days ago

  by    Emily Grosskopf

This job is no longer available.

Who We Are

We are a leading not-for-profit health insurer in Wisconsin, and our services have grown to reach active-duty and retired military personnel, seniors, and families in Wisconsin, across the U.S., and around the world. 

More specifically, WPS Government Health Administrators (WPS GHA) has served Medicare beneficiaries since 1966, providing over 50 years of service to the Centers for Medicare & Medicaid Services (CMS) and the Medicare program. Our mission is to provide service and value considered by our customers to be the very best. We remain committed to providing the best in service to Medicare beneficiaries and providers through emphasis on uncompromising business ethics and long-term sustained performance excellence. It has long been our goal to serve our Medicare customers more effectively while lowering our costs and improving productivity.  


WPS is very proud to again be named one of the "World's Most Ethical Companies" in 2018 by the . This is the ninth consecutive year WPS has received this honor, which attests to our dedication and commitment to a higher ethical behavior. Ethisphere reviewed thousands of nominations from companies around the globe. This award is reserved for organizations that demonstrate exceptional ethical leadership, commitment to social responsibility, and outstanding compliance performance.

At Our Core

WPS Health Solutions has earned a reputation as a leader in the insurance and benefits administration industry through our commitment to excellence and high-quality service. Our corporate values reflect the core of who we are and how we conduct business every day.

Customer Focused

I recognize how my actions impact internal and external customers by being responsible for the customer experience. I look beyond the immediate issue to recognize and solve the problem.

Individual Responsibility

I own my actions. I am accountable and dedicated to achieving the best results for WPS Health Solutions and our customers. I embrace my role in helping the company achieve a high-performance workplace.

Mutual Respect

I lead by example and act ethically, honestly and am trustworthy. I show appreciation for others by giving and taking constructive feedback and encouragement. 

Driven and Passionate

I approach my work with enthusiasm, and personal commitment to the success of our business. I keep the importance of the work we do for our customers alive in my attitude and interactions with others, and demonstrate pride in the worthiness of our purpose.

Position Summary

The Vice President of Operations and Medical Review will provide oversight on all WPS Medicare Contracts for Medical Review and Data Analytics. Will provide leadership and executive guidance on medical review, data analytics, policy and coverage.

In this role you will:

 Leadership and Personnel Management (55%)

  • Manage Medical Review and HealthcareInformatics by coaching, mentoring, educating, and motivating toward achievement of WPS GHA strategic goals.
  • Provide oversight to management team to ensure necessary tools and resources are available.
  • Ensure WPS meets CMS requirements and award fee objectives.
  • Oversee Targeted Probe and Education process and ensure correct identification of problem areas and/or providers.
  • Oversee data analytic projects and identify areas for further advanced analytics, research work on provider outliers or areas of concern. Monitor for patterns of risk.
  • Prepare budget documents, projections, and productivity needs to ensure alignment of resource needs with budget levels.
  • Problem-solve situations for effective solutions.
  • Make decisions as needed to ensure efficient daily operations.
  • Prepare overall GHA project needs for budget.

Strategy (35%)

  • Participate in strategic planning to determine objectives and ensure plans are meeting set objectives.
  • Develop contracts and work requirements for partners.
  • Drive and maintain consistency towards GHA strategic plan.

Customer Relationship Management (15%)

  • Build and maintain positive working relationships with CMS and partners.
  • Monitor resolution of identified issues and appropriate corrective actions are taken.
  • Lead and participate in work groups with other MAC's and CMS staff on items of local and national concern.
  • Provide clinical expertise and direction for Local Coverage Determinations (LCDs) development, and maintenance at local and national level.
  • Assist OIG, US Attorney Offices, UPIC, and appeals on investigations and case development.
  • Provide support to corporate initiatives beyond GHA division.

* This job profile is not intended to be an exhaustive list of all duties or responsibilitiesassociated with the job. Other job-related duties may be assigned.

You should have:

  • Bachelor's Degree in Business Administration, Finance, Nursing, Data Analytics or related
  • field OR equivalent post high school education with relevant medical coursework and/or
  • related work experience
  • Ten (10) years of progressively responsible business experience, which includes seven plus
  • (7+) years of proven leadership/managerial experience
  • Proven experience in building strong collaborative teams in a dynamic culture
  • Strong experience in identifying efficiency gaps and implementing process improvement
  • solutions to correct those gaps
  • Experience in planning and overseeing a budget

We also prefer:

  • Experience working for/with a Medicare Administrative Contractor (MAC) or government contractor
  • Strong clinical or data analysis skills



Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information.