Sr Medical Director – Utilization Management - job 1 of 2

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. 

About the opportunity: 

As Senior Medical Director for Utilization Management (UM), you will be an effective change leader and help develop and guide the strategic direction for Utilization Management initiatives at Wellmark. As a leader of others, you will directly impact the success, growth, and development of team members by setting clear expectations, coaching to each team member’s strengths, and fostering a team-centric work environment. Being a role model in behaviors that demonstrate  Wellmark’s Leader Success Expectations and inclusion are essential. 

A top candidate will be a self-directed and results-oriented physician who leads by example to serve as Wellmark's subject matter expert on effective and efficient processes to reduce overuse and improve quality for our members. You will strategically collaborate with the Health Services team and across the organization to develop and maintain accountability for initiatives to reduce overuse with results that are validated by Wellmark’s analytical team and are grounded in evidence-based care. Internal + external relationship and trust building is essential for success.

About you: 

You believe health care can be better and are passionate about finding ways to influence this important work. You are proactive, analytical, innovative, and partner effectively with internal and external stakeholders. You are a skilled communicator and enjoy collaboration with other cross-functional leaders. You are someone who can pivot easily: from performing UM and appeals case reviews, to driving employee engagement and collaboration amongst your team and others, to strategically partnering to develop new total cost of care (TCOC) initiatives. You enjoy variety in your day. You are confident in your decision-making skills and can jump in to assist the team with utilization management while also leading high-level initiatives. You see yourself as a forward-thinking professional and thrive when your work allows you to tap into your creative side to build impactful work from the ground up. 

Preferred Qualifications - Great to have:

• Board certified in Internal Medicine.
• Experience working in a Hospitalist capacity.
• Involvement in transformational health care initiatives/projects.

Required Qualifications - Must have:

• 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 OR an administrative license; 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 or American Osteopathic Association.
• 3-5 years of Utilization Management experience in Commercial programs at a large and complex managed care organization. A track record of accomplishment as a clinical leader demonstrating increasing responsibilities and expertise is essential.
• Masterful at delivering timely UM decisions based on evidence, cogent clinical reasoning, benefit information, applicable policies, and other relevant information.
• Demonstrated formal or informal leadership experience.
• Strong interpersonal skills are mandatory, including clear and concise written and verbal communication. Inquisitive nature, enthusiastic by developing and enacting new processes.
• Proven ability to set clear goals/expectations and motivates teams to achieve success with an eye toward promoting a culture of collegiality and excellence.
• Demonstrated sense of ownership, drive and initiative to continuously improve outcomes.
• Serve as change champion to inspire and influence stakeholders to achieve an organization initiative. 
• Track record of teamwork including sharing accountability, influencing without direct authority, effectively listening to others, and effectively leading cross-functional teams to deliver results.
• 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.
• Demonstrated domain knowledge and ability to be conversant with interpretation and application of data and analysis at the highest level and broadest scope. Possesses superior analytical skills.
• Proficiency with Microsoft Office applications – e.g., Word, Outlook.

What you will do as a Sr Medical Director - Utilization Management:

a. Demonstrate ownership of overall effectiveness and efficiency of UM process and outcomes in close partnership with Director, UM in Health Services.

b. Demonstrate deep expertise in delivering UM inpatient and outpatient decisions, especially on complex cases.  Ensure that decisions are consistent with Wellmark’s contractual definition of medical necessity based on (a) high quality clinical evidence; (b) sound clinical reasoning in areas of where the evidence is not definitive; and (c) review of clinical documents submitted by the requesting provider.

c. Provide leadership and day-to-day management of financial and human resources, primarily focusing on employee and leader coaching, development, performance improvement, coordination and budgeting for multiple staff, and department specific functions/services. Train and mentor physician team as needed and facilitate ongoing team-based learning within physician UM team using weekly case review rounds as a central two-way learning opportunity (i.e., everyone learns from each other on a team). Ensure that efficient and effective performance of UM physician team as evidenced through meaningful metrics that are tied to key business outcomes for quality, affordability and experience.

d. Responsible to perform oversight of independent review organization appeals and ensure effectiveness of end-to-end process for medical appeals in close partnership with nursing leader of appeals process.

e. Responsible for providing exemplary engagement on peer-to-peer calls and escalated UM cases. Consult with stakeholders as needed to ensure that UM decision-making is holistic and consistent with Wellmark’s contractual definition of medical necessity. Effectively engage with external physicians, health care facility UM leadership, and other stakeholders to improve the efficiency and effectiveness of Wellmark’s UM program.

f. Responsible for oversight of delegated specialty UM vendor clinical decision-making. Audit UM decisions to ensure compliance with Wellmark’s contractual definition of medical necessity. Resolve issues that are identified through auditing, monitoring and feedback. Address root cause and ensure corrective action implemented and audited.

g. Partners with and demonstrate effectiveness with Wellmark’s Business Analytics team to drive each component of product development/new total cost of care (TCOC) initiatives to reduce overuse using the below model. We use the Product Operating Model, and the core concept related to reducing overuse is: (a) use data to identify actionable overuse opportunities; (b) apply industry experience to identify and validate proposed interventions; (c) build a business case to articulate the impact; and (d) work through implementation to secure the result through measurable outcomes (i.e. Funnel, Reviewing, Analyzing, Ready, Implementing MVP, Implementing Persevere, Value Realization/Closed, etc.).

h. Perform other initiatives and projects as required.

This job requires a non-compete agreement.

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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