The health care industry is evolving and Wellmark is working to help change it for the better.

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.

You can also learn more about working at Wellmark here.

Help us lead the change as we build out our Payment Integrity Team at Wellmark!

About the Role: As a Team Leader, you will drive strategic initiatives that support the development, analysis, innovation, and maintenance of Wellmark's payment integrity goals. You will be key in leading a team of Payment Policy Analysts to facilitate accurate claims payments to ensure precise payments are made through the right benefit program and to correct right provider. You will leverage your strong Microsoft Excel experience to conduct trend analysis and evaluation of improvements that can be implemented. This position will require an understanding of claims management and, ideally, payment integrity to support the goals of the business and to support the team towards successful payment integrity outcomes.

About You: Because this role is a leader of others, this individual will directly impact the success, growth, and development of team members by establishing goals and objectives, setting clear expectations, defining accountabilities, providing regular coaching, facilitating change, and providing an overall positive work environment. Being a role model in behaviors that demonstrate Wellmark’s core competencies is a must. In addition to a passion for developing others, our ideal candidate is skilled at change leadership; effectively managing change will be critical from establishing the business case for change, to operationalizing and communicating evolving business processes both internally and externally. You are a self-starter who can work autonomously but also enjoys regular collaboration across teams to reach a common objective. You are proactive, analytical, innovative, and are a skilled communicator. You enjoy work where you can leverage team member strengths to drive impactful results. You love to teach and understand the benefits of transparent, dedicated leadership, because your team members’ individual achievements mean success for Wellmark.

Top candidates will have claims processing and adjusting experience utilizing Facets.

Required:

• Bachelor’s degree in business, health care administration or related field.
• Minimum of 5 years’ health care or health plan experience including a minimum of 4 years of progressively responsible experience in various functions of payment integrity, such as claims editing/auditing, medical record reviews, etc.
• 3+ years of experience investigating, researching, and analyzing claims data applying knowledge of payment and/or medical policy to determine details for inaccurate billing activity. Familiarity with claim payment methodologies, professional and facility coding, billing software/analytics platforms, etc.
• Leadership skills typically gained through a combination of project or informal leadership that demonstrates knowledge of work processes, services, or leadership competencies. Ability to effectively coach and mentor others and lead teams through change.
• Prior experience leading and managing enterprise-wide programs/projects, teams, external vendors and cross-functional initiatives. Creative, continuous improvement-focused approach. Forward-thinking, proactive, thoughtful approach to project management with the ability to learn quickly, effectively manage and implement multiple, competing priorities in a fast-paced, dynamic work environment.
• Strong financial analysis and risk management skills. Experience demonstrating effective resource management, budgeting, forecasting and strategic planning with the ability to provide in-depth analysis and recommendations to senior leadership using critical thinking and sound judgment.
• Strong written and verbal communication skills. Ability to present complex information to diverse audiences and effectively facilitate meetings. Demonstrates solid relationship building and negotiation skills to establish trust, build consensus and drive results. Possesses effective consulting skills with the ability to solicit cooperation and action from others by creating a sense of urgency and a teachable point of view.
• Thorough understanding of all core healthcare operational departments as well as healthcare laws, regulations, and standards. Knowledge of applicable regulations governing healthcare fraud, waste, and abuse and potential implications to the department.

Preferred:

• Experience in the health care industry, preferably with a focus on payment integrity programs and activities.
• Extensive knowledge of health-care regulations, legislation and laws, auditing reports and system functions, with in-depth operational experience of medical billing, coding and provider claims processing and adjustment.
• Large scale Process Improvement and/or Business Project Management experience.

a. Provide day-to day leadership and management of payment integrity team members, and matrixed subject matter experts, primarily focusing on establishing and supporting a culture of collaboration, teamwork, and performance improvement. Lead in a way that enables the development of skilled team members to handle the variety of tasks assigned, through coaching, mentoring, and nurturing innovative ideas, which also support Wellmark and divisional strategy and goals and maintain a sustainable competitive advantage.

b. Ensure performance of comprehensive research and identifying billing abnormalities, questionable billing practices, and / or other irregularities. Provide guidance to members involved with payment integrity efforts across the organization.

c. Lead the investigation, research, and analysis of claims data that applies knowledge of payment and/or medical policy to determine details of unusual, wasteful, or abusive billing activity. Present information in a format that is relatable to interested parties.

d. May provide oversight of vendor concepts, partnering with vendors and internal stakeholders on strategic direction, collaborating with workgroup and governance committees.

e. May provide oversight of inquiries received, tracking production and performance metrics, completing trend analysis, and partnering with internal stakeholders to create efficiencies.

f. Serve as critical partner for approved payment integrity projects and initiatives, as applicable. Monitor project plan results, adjusting plans and performance expectations to achieve targeted results. Support team and provide guidance in determining the best solutions and movement from concepts/ideas to processes. Adapt departmental plans and priorities to address business and operational challenges.

g. Provide collaborative consultation and input on product, service or process decisions that are most likely to impact multiple groups of employees and/or customers (internal or external).

h. Provide direct input to forecasting and planning activities.

i. Develop and leverage meaningful relationships with Health Services, Operations, Finance, Legal and other business stakeholders to ensure coordinated payment integrity activity across divisions, teams and applicable business rules and work streams. Collaborate with strategic business partners to propose solutions that support payment integrity initiatives and goals in alignment with leading practices.

j. Ensure payment integrity processes meet or exceed service and quality standards and are in compliance with Federal and state regulatory and contractual requirements.

k. Other duties as assigned.

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 careers@wellmark.com