Quality Manager-Payment Integrity

Why 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. 

Use your strengths at Wellmark as a Quality Manager for Payment Integrity!   

In this newly created role, you will perform audits of the work performed by Payment Integrity clinical and non-clinical staff. You will also audit incoming and outgoing invoices related to payment integrity, plus create and maintain desk level processes and procedures. Additionally, you will be responsible for the management and oversight of ASO customer audits and will provide quality review reports, results, and trends to payment integrity leadership.  

This is a critical role that will provide and/or assist with cross-training team members on procedures and guidelines for payment integrity functions and assist in the development & implementation of quality and/or process improvements initiatives. While this position is not a people-leader, you will need to build strong internal relationships and trust with team members and other internal stakeholders, leading you to successfully coach and influence the actions of others to meet quality standards. Collaboration is key in this role, so building strong partnerships with teams in Compliance, Audit, Operations, Network Relations, and others will be critical. 

Preferred Qualifications - Great to have:

• Active and Unrestricted Licensed Practical Nurse (LPN) or Registered Nurse (RN) license in Iowa or South Dakota (individual must be licensed in the state in which they reside).

Required Qualifications - Must have:

• Associate degree or direct and applicable work experience.
• Coding certification- e.g., CPC, CPC-P, COC, CCS-P, RHIT, or RHIA.
• 4+ years of work experience in payment integrity, SIU, insurance operations, coding, claim processing, contracting, credentialing. medical policy, or similar areas.
• 2+ years of work experience completing audits or coordinating audits.
• Strong ability to coach and mentor others with regards to audit results.
• Excellent analytical, research, and critical thinking skills, demonstrating the ability to review, analyze, and interpret regulations and other guidelines and provide insights or recommendations.
• Ability to effectively evaluate data/trends, solve practical problems, and conduct audits and research as needed.
• Quality assurance and process improvement mindset.
• Effectively manages competing priorities in a fast-paced, dynamic work environment. Flexible and adaptable to changing priorities is a must.
• Ability to measure and evaluate work processes and utilize appropriate resources to identify opportunities or implement solutions.
• Ability to build relationship and consult with stakeholders, apply subject matter expertise and influence decisions appropriately.
• Proficient with Microsoft Office (e.g., Word, Excel, Outlook) and web-based applications (e.g., PolicyTech), with the ability to learn new technology quickly.

What you will do as a Quality Manager for Payment Integrity:

a. Develop and manage multiple audit projects including work done by clinical and non-clinical team members, incoming and outgoing InterPlan invoices, and third-party audits requested by ASO groups (both Wellmark and non-Wellmark groups) in which payment integrity functions have been performed.

b. Provide timely and accurate information regarding procedural/documentation concerns, team needs, and error trends to the payment integrity leadership team. Information provided will include team and individual contributor quality reports shared with leaders regarding quality results, error trends, and issues that must be addressed, including reporting on trainee results and progression towards regular quality reviews.

c. Compile and maintain audit documentation to support audit work performed, issues and conclusions identified and recommendations/action plans. Create desk-level audit procedures, as necessary.

d. Lead, collaborate and consult with business unit leaders by researching issues identified in quality reviews by performing additional investigation as necessary to drive consistency and accuracy.

e. Develop and monitor corrective action plans for any identified audit issue, including partnering with Wellmark’s Compliance team on any issue resolutions that may be necessary.

f. Establish and maintain positive team member relationships and provide mentoring and coaching performance by providing quality assurance feedback and subject matter.

g. Lead project and process improvement initiatives, when appropriate.

h. Share and encourage ideas and collaborate with the team to create efficiencies in work processes and efforts.

i. Comply with regulatory standards, accreditation standards and internal guidelines; remain current and consistent with the standards pertinent to the payment integrity and Network team.

j. Alert Wellmark’s internal Compliance team of any variances that need to be documented and addressed at the corporate level and partner with this team to resolve variances.

k. Other duties as assigned.

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 [email protected]

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