Job Description

HELP US LEAD CHANGE AND TRANSFORM THE MEMBER EXPERIENCE 

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’re embarking on a journey to help 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.

USE YOUR STRENGTHS AS CLINICAL APPEAL CONSULTANT

In this role, you'll coordinate and support clinical appeal and special inquiry activities as required by federal and state mandates, accreditation standards, and Wellmark administrative and clinical policies, processes, and criteria. You will provide assessment and written analysis of individual case review and the consistent application of applicable criteria, rules, provider payment processes and member benefits, while assuring compliance with regulatory rules and accreditation standards related to clinical appeals and special inquiries. In addition, you will serve as a resource and subject matter expert to all levels within the organization on accreditation and compliance as related to appeal activities. (Clinical appeals and special inquiries are defined as member and provider appeals, and CEO, legislative, Insurance Division in IA or SD and attorney special inquiries.)

Our strongest candidates love to conduct research and make evidence-based decisions and recommendations. They have a knack for coordinating/managing multiple deliverables in different stages -- they're skilled at tracking details and prioritizing work effectively. Although they are independent workers, they have very strong interpersonal skills and collaborate well with others.

Qualifications

REQUIRED:

• Associate’s degree from an accredited nursing program.
• 4+ years of experience as a Registered Nurse (or related role) in a health care delivery or managed care setting. Ability to review medical cases and literature, familiarity with physician practice patterns and billing practices, and knowledge of diagnosis and procedure coding systems. Must be able to draw defensible conclusions from available information.
• Knowledge of the health insurance industry, as well as utilization and quality management practices - e.g., case and disease management, member certificates, accreditation coordination, or provider contracts. General understanding of UM criteria or provider payment rules, appeals, regulations, and workflow management.
• Excellent analytical, time management and problem solving skills. Strong attention to detail and the ability to identify, research, and analyze issues, organize information, and make appropriate decisions. Ability to identify root causes for opportunities for improvement in benefit determinations and assess downstream impacts.
• Strong written and verbal communication skills with the ability to negotiate and communicate complex concepts to internal and external stakeholders. Ability to present information to varying audiences.
• Ability to measure and evaluate work processes, and utilize appropriate resources to identify next steps, potential impacts/risks, and solutions.
• Strong deductive reasoning skills to probe, research, ask questions, actions and make decisions that incorporate data, and seek to understand. Ability to weigh alternative opinions, facts, tangible and/or intangible factors.
• Proficiency with Microsoft Office applications. Ability to run reports, construct documents, organize data, etc.
• Role requires Active and Unrestricted Registered Nurse (RN) license in Iowa or South Dakota (individual must be licensed in the state in which they reside).

Additional Information

a. Collaborate with various teams including Medical Directors, Special Inquiries, Pharmacy Operations, Health Services, Federal Employee Plan Team, Corporate Compliance, and contracted vendors to coordinate, assess, and analyze clinical aspects of the clinical appeal and special inquiry activities, minimizing Wellmark’s litigious risk from regulatory and civil suit. This includes awareness and application of the organization’s performance of related standards, laws, policies, and procedures dictated by regulatory rules and accreditation standards. b. Process clinical appeals and special inquiries judiciously and within parameters set internally as well as externally. This includes working with various areas within Wellmark related to consistent application of said regulations, processes, clinical criteria, policies, payment processes, and operational guidelines. c. Comply with regulatory standards, accreditation standards and internal guidelines; remain current and consistent with the standards pertinent to the Clinical Appeal Team. d. Research, analyze, and solve complex issues related to the clinical appeal and special inquiry process in a self-directed manner, utilizing the foundations within the Wellmark structure, established process guidelines and standards and seeking guidance from the Senior or Team Leader on the most complex tasks. Identifies solutions to non-standard requests and problems, and follows associated protocols. e. Serve as liaison with clinical providers, facilities, and internal staff concerning issues with members and providers regarding various Wellmark program definition and clarification pertaining to the individual appeal. This includes providing explanations and information on difficult issues both verbal and written. f. Identify and support implementation of improvement initiatives that promote the delivery of appropriate identified care, coordinated to preserve member benefit dollars as well as improving member health status and satisfaction with Wellmark as related to clinical appeal and special inquiry activities. Identify and report quality of care and service issues through the designated process. g. Identify opportunities for process and program improvement, and provide input in regards to supportive tasks associated with the implementation of initiatives. Support 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. As directed performs clinical assessments associated with appeals and special inquiries, and provides feedback to the Medical and Pharmacy Policy Development process. h. Assess and analyze core denial and appeal processes assisting with identification and implementation of quality improvement or process management activities. i. Other duties as assigned.

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