***Please note that Wellmark is leveraging a Search Partner for this role. Any information you provide may be shared with this firm as part of our assessment process.***

Help us lead change and transform Wellmark's business!

The health care industry is changing, and Wellmark is working to help change it for the better. We recognize that our members deserve health care with a focus on quality. We also recognize that health care is complex. We’ve embarked on a journey to support our members use and navigate the health care system in order to help them make clear, informed decisions, and we’re also ensuring that we take a team-centric approach when working with and in support of our members. The work that our diverse business and care teams are doing in collaboration with our health care partners will create these changes, all while working to minimize health care costs.

Check out more about working at Wellmark here.

Learn more about Wellmark's unique benefit offerings here. 

About the role: As Senior Medical Director for Utilization Management, 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 within Health Services 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. 

What does it take to make the cut? 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 and enjoys 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. 

Required:

• 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, American Osteopathic Association, or National Board of Physicians and Surgeons.
• 5+ years of clinical utilization management practice experience in managed care, in a Medicare Advantage or Commercial environment, and 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.
• Demonstrated leadership experience, including building/developing high performing teams. Establishes clear goals/expectations and motivates teams to achieve success.
• 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 care business models including reimbursement.
• Expertise in leveraging industry knowledge, technical expertise, and relationship building skills to quickly build rapport, credibility, and collaborative partnerships with clinical peers, leaders, and stakeholders; applies skillful consulting abilities to influence corporate decisions.
• Very strong change management skills. Creates a clear view of future state and inspires others to advance the vision.
• Success mentoring and working within teams, including sharing accountability, influencing without direct authority, effectively listening to others, and effectively leading cross-functional teams to deliver results.
• 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. Demonstrated domain knowledge and ability to be conversant with interpretation and application of data and analysis at the highest level and broadest scope. Possess superior analytical skills.

Preferred:

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

a. Provide oversight for Utilization Management physician team to ensure evidence-based clinical decision-making to reduce overuse and improve quality. Provide clinical leadership to improve quality, affordability, and experience by reducing overuse.

b. 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.

c. Collaborate with VP, Heath Services to ensure efficient and effective utilization management processes to reduce overuse.

d. Utilize managed care experience and expertise to enhance and support processes within Health Services and across Wellmark to solicit and organize ideas to reduce overuse. (Ideation)

e. Work with Business Analytics team to build a fact-basis for potential clinical interventions. (Validate)

f. Continue to partner with Business Analytics and other stakeholders to prioritize potential interventions to reduce overuse. (Prioritization)

g. Partner with BA team and stakeholders to develop cost/benefit/plausibility analysis. (Initial Sizing)

h. Partner with stakeholders to build business case using work product from Initial Sizing: Problem Statement; Issue tree; Work Streams and Analysis. (Business Case)

i. Test/Implement/Go-Live/Maintain accountability for result. (Launch)

j. Partner with Medical Policy Medical Director: operationalize and IRR on complex policies and provide feedback on medical policies with issues. (Two-Way Communication)

k. Ensure that UM dashboard metrics for physician team are met/exceeded. (Metrics)

l. 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]