nearmejobs.eu
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.
Want to know more? You can learn about life at Wellmark here.
About the Opportunity: As an experienced M.D. or D.O. in adult acute care setting(s), you will use evidence-based decision making to perform inpatient case reviews that are timely and clinically appropriate. You will concisely, effectively, and consistently synthesize clinical information to document a clear summary of a medically necessary determination. While case reviews are this role’s primary priority and function, you will have the opportunity to make recommendations on efficiencies and innovations to ensure our members are getting appropriate and timely care based on their health plan coverage. You will partner across the organization with other internal teams, such as Business Analytics, Claims, Operations, Actuarial, and BlueCard, to name a few. Join us on this continuous journey as we make health care better for our members!
About You: You are decisive and have a strong ability to influence internally and externally by appropriately and effectively presenting evidence-based medicine to support a determination. Critical thinking, sound judgment, and decisiveness are key; however, you will be able to draw from your colleagues’ subject matter expertise from various departments, to help make evidence-based prior authorization decisions. You are collaborative by nature and are energized by the opportunity to work in a highly integrated and matrixed culture. Managed care experience in a large commercial organization, such as at another Blue Cross & Blue Shield plan, a plus.
If this sounds like you, apply to our Medical Director-Inpatient Utilization Management opportunity today!
Iowa or South Dakota-based candidates preferred but open to remote for the right candidate.
This full-time position will also work a rotating on-call schedule for weekend and holiday reviews.
Required Qualifications:
Preferred Qualifications:
What you will do as a Medical Director for Inpatient Utilization Management (UM):
a. Demonstrate ability to apply clinical experience in the care of patients in an acute care hospital setting to render medical necessity determinations for adult acute inpatient care. The foundation for Wellmark’s definition of medical necessity is Evidence-Based Medicine and evidence of sound clinical reasoning.
b. Concisely, effectively, and consistently synthesize clinical information to document a clear summary for the basis of medical necessity determinations. The documentation in the UM record will reflect the ability to act timely and decisively based on the clinical records that were submitted to support the medical necessity for inpatient level of care.
c. Develop an effective and collaborative relationship with Wellmark’s UM leaders to continually improve the end-to-end UM process by providing ideas and feedback on improvement. Actively identify opportunities for process improvement or the need for new processes that are observed in the course of day-to-day work. Demonstrates openness to receiving and acting on constructive feedback.
d. Defend UM decisions internally and externally using evidence-based medicine, sound clinical reasoning, and critical thinking skills. Actively listen for relevant new information and compelling counterarguments. Revise decision when the fact basis requires it.
e. Demonstrate sound judgment by seeking consultation from leader on complex UM case reviews.
f. Effectively engage in peer-to-peer calls. Seek to understand new information that the provider may offer. Effectively and concisely uphold the UM decision or revise the UM decision based on new information when necessary.
g. Perform overflow Outpatient reviews as needed.
h. Deep knowledge of, and proficiency in applying, Wellmark’s medical policies, especially for commonly requested outpatient services.
i. Participate in rotating on call schedule for weekend and holiday reviews.
j. Other duties as assigned.
This job requires a non-compete agreement.
Remote Eligible: You will have the flexibility to work where you are most productive. This position is eligible to work fully remote. Depending on your location, you may still have the option to come into a Wellmark office if you wish to. Your leader may ask you to come into the office occasionally for specific meetings or other ‘moments that matter’ as well.
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 careers@wellmark.com
Please inform us if you meet the definition of a “Covered DoD official“.
Apply
To help us track our recruitment effort, please indicate in your cover/motivation letter where (nearmejobs.eu) you saw this job posting.
Job title: Medical masseur (m/f/d) - part-time Company Therme Wien Job description Ihre Karriere in…
Job title: Registered Nurse - $8000 Sign on + Relocation support Company Churches of Christ…
Job title: SECRÉTAIRE MÉDICAL(E) (F/H) URGENT PROFIL FRAPPE DE COMPTE RENDU Company Appel Médical Job…
Job title: LA Galaxy Academy, Academic Tutor (English) - Part-Time Company AEG Job description For…
Job title: CE Supervisor Company Job description @maynoothcep.com or addressed to: Paul Croghan, Company Secretary,…
Job title: Interim Nordic Facility & Store Cost Manager Company Foodora Job description understanding of…
This website uses cookies.