Wellmark’s Medical Director translates their finely-tuned clinical expertise into Wellmark’s Medical Management department to improve outcomes and manage medical benefit costs through evidence-based medical reviews. Your broad clinical background and passion for patient care and sustainability of the health care system will be critical to your success in providing value to our providers and members. A highly collaborative sense of teamwork, good reputation with providers, and commitment to the health and well-being of Iowans and South Dakotans will be key to success in this role.
This position will require a signed non-compete agreement upon hire.
1) Within your first 30 days, you will develop a demonstrated understanding of the department including a deep dive into the workflows of fellow Medical Directors through job shadowing. You will also become familiar with relevant IT systems.
2) Within your first 60 days you will meet with stakeholders in various departments including but not limited to the following:
You will also develop an understanding of the interactions of the Medical Review function with other areas of the business outside of Provider Relations and Health Management including Operations, Sales, Marketing, and Finance.
3) On a daily basis, you will receive escalated cases for review within Wellmark’s Care Management software. These cases require a keen clinical eye to provide valuable insight in the process of assessing medical necessity against evidence-based criteria. You will incorporate your clinical expertise into your review of these cases to create value for patients in a non-clinical environment.
4) The Care Management team works continuously to review current internal processes for areas of opportunity. As part of the Medical Director team you will be intimately involved in formal process improvement events and implementations. You will also be expected to contribute to continuous improvement efforts and play an active role in identifying opportunities to create a sustainable health care system in Iowa and South Dakota. You will use your knowledge of quality and process improvement methodologies to conceptualize ideas and seek out opportunities to document and improve processes within your own workflow and share learnings with members of your team.
5) You will review and analyze medical benefit expenses to help support Wellmark’s sustainability initiatives and the delivery of affordable premiums to members by examining medical trends, evaluating new technologies and procedures, and monitoring coding practices. You will incorporate clinical knowledge, continuous education, and business savvy to provide valuable insight into areas of opportunity and improvement for Wellmark and our member/provider communities. You will support the CMO in identifying various opportunities to leverage claims data to highlight practice pattern variation and recommend programs or interventions to eliminate waste and will actively participate in the development and deployment of provider payment methods that will support accountable care. You will also demonstrate rigor around evaluation and relative payment for new medical technology based on evidence, recommend new approaches, and exhibit influence within the provider community to deliver better care at a lower cost.
6) You will serve as a role model for Wellmark’s philosophy “It Starts With Us," a commitment to the health and wellness of our employees and our communities, which translates into a commitment to a healthy company and team culture. You will set an example for others in regards to work/life balance, wellness, and stress management, as well as in cultivating a dynamic, collaborative culture through interactivity within your own closely-knit Medical Director team and teams with which you interact within the larger organization. There are no lone-wolves here; our team of Medical Directors thrives in a highly collaborative environment of ongoing learning and knowledge transfer.
Wellmark's Core Competencies:
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; 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.
4+ years of clinical practice experience 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.
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.
Industry knowledge, technical expertise, and strong relationship building skills to quickly build rapport, credibility, and collaborative partnerships with clinical peers, leaders, and stakeholders.
Demonstrated success leading and working within teams, including sharing accountability, influencing without direct authority, effectively listening to others, and effectively leading cross-functional teams.
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.