Quality Management Consultant

Location US-IA-Des Moines
Job ID
Clinical/Provider Support
Requires Non-Compete?

Job Summary

Wellmark is hiring a Quality Management Consultant to support the quality management program (QMP) including accreditation, HEDIS and compliance activities. This individual will manage core business processes and quality activities in an effort to support member health improvement. A key focus are will be successful HEDIS submissions and assuring compliance with state and federal regulations and accreditation standards. Additionally, this individual will serve as a resource and subject matter expert to stakeholders and leaders within the organization on the QMP and HEDIS..


This particular opening will ensure organizational compliance with NCQA, state, and federal requirements, along with internal policies and procedures. The incumbent will develop program material, manage the completion and delivery of program documents according to detailed timelines, work closely with internal business partners and external stakeholders and manage the HEDIS the programs HEDIS submission process. Prior experience is desired in the areas of NCQA and HEDIS standards and accreditation, identification and execution of best practices, and/or proven experience in program management that resulted in high performance outcomes.

Minimum Qualifications Required (all must be met to be considered)

  • Bachelor's Degree or direct and applicable work experience.
  • 4+ years of work experience in a quality management, accreditation coordination, or related role from within a clinical, health care delivery, managed care, or similar setting.
  • 1+ year of health insurance operations or related industry experience, including exposure to quality assurance principles or techniques.
  • Ability to review standards, business policies and procedures, health care literature, and/or medical cases. Must be able to draw defensible conclusions from available information.
  • Knowledgeable in regulatory standard or regulation review – e.g., NCQA, accreditation standards, confidentiality, and state/federally mandated processes.
  • Strong written and verbal communication skills with the ability to communicate and/or present complex information to stakeholders.
  • Excellent analytical, diagnostic problem solving skills. Strong attention to detail and the ability to identify, research, and analyze issues, organize information, and make appropriate decisions. Ability to view the big picture when making decisions.
  • Demonstrated success in roles that require strong time management and workflow management skills. Ability to prioritize effectively and manage multiple projects. 
  • Proficiency with Microsoft Office applications, specifically Excel. Ability to run reports, construct documents, organize data, etc.

Hiring Specifications Preferred

  • HEDIS experience.
  • Active and unrestricted RN license in Iowa or South Dakota.
  • CPHQ certification.



Job Accountabilities

a. Provide coordination for the Wellmark HEDIS program including measurement process and ensure adherence to audit standards and technical specifications. Collaborate and coordinate work with the contracted Certified HEDIS Software vendor, and independent HEDIS Auditor in the development and execution of business relationships and improving the HEDIS process.

b. Educate and engage Wellmark internal and external stakeholders on Wellmark’s quality management program (QMP) accreditation, HEDIS and compliance activities. This includes fully informing all appropriate Wellmark staff and appropriate owners of processes of accreditation and compliance requirements, and what specifically is required to stay compliant with said standards. Collaborate on solutions in the process of compliancy.

c. Comply with regulatory standards, accreditation standards and internal policies and remain current with the standards pertinent to the QMP.

d. Coordinate the assigned accreditation/audit functions during onsite surveys.

e. Participate and provide feedback on potential gaps in Wellmark performance and associated risks to accreditation.

f. Identify, recommend and implement quality improvement initiatives that promote the delivery of appropriate identified care, coordinated to preserve member benefit dollars as well as improving member health status, and member satisfaction with Wellmark.

g. Provide critical quantitative and qualitative analysis, identify opportunities for improvement identified and implement with subsequent measurement and analysis of the interventions that equip Wellmark, members and providers to manage the health care of our members, or internal processes or policies.

h. Develop quality improvement reports and dashboards and present to the Quality Committee, other stakeholders and internal business partners.

i. Support the annual HEDIS reporting process.

j. Develop and implement quality improvement work plans, evaluate and report findings to Quality Committee at required intervals.

k. Provide support of the Wellmark Quality Committee. Attend and or provide staff support of assigned committees.

l. Provide support to the Network Administrative leadership team by interacting with Wellmark corporate compliance team to assess impacts from state and federal regulatory requirements, and BCBSA mandates. This includes maintaining the compliance matrix specific to the Quality Management Program, and communicating to leaders when new or existing compliance activities need assessed or completed. This includes supporting the Business Continuity Planning and preparation process.

m. Other duties as assigned.


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