Wellmark, Inc.

Lead utilization management initiatives, oversee clinical decision-making, manage and develop physician teams, collaborate on cost of care projects, and ensure compliance with medical necessity policies. | Must have an MD or DO with active medical license, board certification, 3-5 years utilization management experience in commercial managed care, leadership skills, and strong communication and analytical abilities. | 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. Job Description As a Sr Medical Director, you will be eligible to work remotely from your home location, with the expectation of the following travel to the Des Moines, Iowa office: • First 6 months/Onboarding: Every other week in Des Moines, IA • After 6 months: Quarterly in Des Moines, IA • Additional travel may be required to meet business needs Candidates in the Central Time Zone and/or with a direct flight to Des Moines, Iowa are preferred. About the opportunity: As Senior Medical Director for Utilization Management (UM), you will be an effective change leader and help develop and guide the strategic direction for Utilization Management initiatives at Wellmark. As a leader of others, you will directly impact the success, growth, and development of team members by setting clear expectations, coaching to each team member's strengths, and fostering a team-centric work environment. Being a role model in behaviors that demonstrate Wellmark's Leader Success Expectations and inclusion are essential. A top candidate will be a self-directed and results-oriented physician who leads by example to serve as Wellmark's subject matter expert on effective and efficient processes to reduce overuse and improve quality for our members. You will strategically collaborate with the Health Services team and across the organization to develop and maintain accountability for initiatives to reduce overuse with results that are validated by Wellmark's analytical team and are grounded in evidence-based care. Internal + external relationship and trust building is essential for success. About you: You believe health care can be better and are passionate about finding ways to influence this important work. You are proactive, analytical, innovative, and partner effectively with internal and external stakeholders. You are a skilled communicator and enjoy collaboration with other cross-functional leaders. You are someone who can pivot easily: from performing UM and appeals case reviews, to driving employee engagement and collaboration amongst your team and others, to strategically partnering to develop new total cost of care (TCOC) initiatives. You enjoy variety in your day. You are confident in your decision-making skills and can jump in to assist the team with utilization management while also leading high-level initiatives. You see yourself as a forward-thinking professional and thrive when your work allows you to tap into your creative side to build impactful work from the ground up. Qualifications Preferred Qualifications - Great to have: • Board certified in Internal Medicine. • Experience working in a Hospitalist capacity. • Involvement in transformational health care initiatives/projects. Required Qualifications - Must have: • 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 OR an administrative license; 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 or American Osteopathic Association. • 3-5 years of Utilization Management experience in Commercial programs at a large and complex managed care organization. A track record of accomplishment as a clinical leader demonstrating increasing responsibilities and expertise is essential. • Masterful at delivering timely UM decisions based on evidence, cogent clinical reasoning, benefit information, applicable policies, and other relevant information. • Demonstrated formal or informal leadership experience. • Strong interpersonal skills are mandatory, including clear and concise written and verbal communication. Inquisitive nature, enthusiastic by developing and enacting new processes. • Proven ability to set clear goals/expectations and motivates teams to achieve success with an eye toward promoting a culture of collegiality and excellence. • Demonstrated sense of ownership, drive and initiative to continuously improve outcomes. • Serve as change champion to inspire and influence stakeholders to achieve an organization initiative. • Track record of teamwork including sharing accountability, influencing without direct authority, effectively listening to others, and effectively leading cross-functional teams to deliver results. • 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. • Demonstrated domain knowledge and ability to be conversant with interpretation and application of data and analysis at the highest level and broadest scope. Possesses superior analytical skills. • Proficiency with Microsoft Office applications - e.g., Word, Outlook. Additional Information What you will do as a Sr Medical Director - Utilization Management: a. Demonstrate ownership of overall effectiveness and efficiency of UM process and outcomes in close partnership with Director, UM in Health Services. b. Demonstrate deep expertise in delivering UM inpatient and outpatient decisions, especially on complex cases. Ensure that decisions are consistent with Wellmark's contractual definition of medical necessity based on (a) high quality clinical evidence; (b) sound clinical reasoning in areas of where the evidence is not definitive; and (c) review of clinical documents submitted by the requesting provider. c. Provide leadership and day-to-day management of financial and human resources, primarily focusing on employee and leader coaching, development, performance improvement, coordination and budgeting for multiple staff, and department specific functions/services. Train and mentor physician team as needed and facilitate ongoing team-based learning within physician UM team using weekly case review rounds as a central two-way learning opportunity (i.e., everyone learns from each other on a team). Ensure that efficient and effective performance of UM physician team as evidenced through meaningful metrics that are tied to key business outcomes for quality, affordability and experience. d. Responsible to perform oversight of independent review organization appeals and ensure effectiveness of end-to-end process for medical appeals in close partnership with nursing leader of appeals process. e. Responsible for providing exemplary engagement on peer-to-peer calls and escalated UM cases. Consult with stakeholders as needed to ensure that UM decision-making is holistic and consistent with Wellmark's contractual definition of medical necessity. Effectively engage with external physicians, health care facility UM leadership, and other stakeholders to improve the efficiency and effectiveness of Wellmark's UM program. f. Responsible for oversight of delegated specialty UM vendor clinical decision-making. Audit UM decisions to ensure compliance with Wellmark's contractual definition of medical necessity. Resolve issues that are identified through auditing, monitoring and feedback. Address root cause and ensure corrective action implemented and audited. g. Partners with and demonstrate effectiveness with Wellmark's Business Analytics team to drive each component of product development/new total cost of care (TCOC) initiatives to reduce overuse using the below model. We use the Product Operating Model, and the core concept related to reducing overuse is: (a) use data to identify actionable overuse opportunities; (b) apply industry experience to identify and validate proposed interventions; (c) build a business case to articulate the impact; and (d) work through implementation to secure the result through measurable outcomes (i.e. Funnel, Reviewing, Analyzing, Ready, Implementing MVP, Implementing Persevere, Value Realization/Closed, etc.). h. Perform other initiatives and projects as required. 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 [email protected] Please inform us if you meet the definition of a "Covered DoD official". At this time, Wellmark is not considering applicants for this position that require any type of immigration sponsorship (additional work authorization or permanent work authorization) now or in the future to work in the United States. This includes, but IS NOT LIMITED TO: F1-OPT, F1-CPT, H-1B, TN, L-1, J-1, etc. For additional information around work authorization needs please refer to the following resources:Nonimmigrant Workers and Green Card for Employment-Based Immigrants

Design, develop, test, and maintain data integrations, ETL workflows, and APIs to support business-critical data solutions in cloud or hybrid environments. | Bachelor’s degree or 5+ years experience, strong SQL and backend development skills, experience with ETL and data transformation, ability to collaborate and mentor in an Agile environment. | 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! Why Wellmark Technology? Wellmark is building innovative, modern solutions using cutting edge technology. We are driving organizational transformation and business strategy by empowering our technology team to innovate new and elegant solutions to enhance the customer experience. Together, we are leaning into the future, owning the outcome, and driving organizational change to transform how we work. Job Description We are seeking a talented Software Engineer with a strong focus on back-end development and data to join our team. The ideal candidate will have deep experience working with complex datasets, building scalable data pipelines, and developing APIs that support data-driven applications. This role emphasizes proficiency in SQL and ETL processes. Key responsibilities include designing and maintaining robust data integrations, implementing ETL workflows, and developing APIs using Node.js or other backend technologies. Experience with source-to-target mappings (S2Ts), data transformation logic, and working with structured and semi-structured data is essential. Candidates should be comfortable working in cloud or hybrid environments and collaborating with cross-functional teams to deliver business-critical data solutions. In addition, you will support operational and analytic data needs for the Enterprise CRM team by handling complex data projects and ensuring the completion of data analysis and mapping activities. You will use your strong SQL skills to improve the integration of data from multiple internal and external sources. You will enjoy looking for alternative system solutions to meet overall business requirements. You will design, develop, test, implement, maintain, and document software solutions in support of Wellmark’s business strategy and Technology vision. Ensure completed activities meet specifications, requirements, and Wellmark standards. In addition, participate in determining Technology alternatives and solutions and assist with system integration. Qualifications Preferred: • Previous experience creating data focused Intergrations between web applications • Experience working within an Agile team environment. • Ability or interest in mentoring/coaching others. • Experience partnering with global staffing vendors to deliver projects. • Minimum 2 years' experience with various data techniques such as: gap analysis, data profiling and source to target mapping for both structured and unstructured data sources (ETL, Widgets, JSON, etc.). • Strong expertise in SQL development including knowledge of joining multiple data sources; hands on experience with advanced SQL functions such as creating sub queries, joining, grouping, and filtering to analyze data sources. Required: • Bachelor’s degree in Computer Science, MIS, or related field of study and at least 1 year of software development experience (ex. Angular, NodeJS, TypeScript, C++, .NET, Java, SQL) OR 5+ years of related and applicable experience. • Strong analytical problem-solving skills. Accuracy and high attention to detail. Previous experience troubleshooting and developing creative technical solutions. • Strong ability to gather information, perform necessary research needed for root cause analysis, problem definition and formulation, recommend solution implementation, verification, and ongoing optimization, using data to support recommendations. • Demonstrated ability to build relationships to reach outcomes that gain the support and acceptance of all parties. Ability to communicate key information in a timely manner to the appropriate stakeholder audience with the ability to adjust communication style that will best suit the audience. • Ability to communicate with and coach/mentor team members, while setting an example in maintaining a positive attitude, staying calm under pressure, being approachable, and respectful and taking responsibility when needed. • Ability to thrive in fast-paced environment with changing priorities. Excellent organizational skills. Strong time management skills with the ability to set and meet established timeframes with little direction, while assuring data and information integrity. • Eagerness to learn and stay current on industry trends and have a continuous learning mindset. • Ability to collaborate and work as a team to accomplish goals and/or solve problems. Ability to earn trust and respect from peers, leadership, and stakeholders. Ability to learn by actively listening and applying coaching feedback. • Ability to support and work within a diverse development team model including global staffing, crowd sourcing, etc. Additional Information a. Provide development and/or production support for key software applications and systems. Define, analyze, estimate, develop, test, implement, document, and maintain programs and systems that meet business requirements. b. Contribute to solutions architecture deliverables and decisions, through interpretation of architectural diagrams as inputs to the design deliverable. Apply the reference architecture, contribute to reusable assets, and produce technical specifications sufficient for development teams. c. Partner and problem-solve with the UX team in the development of solutions that improve the user experience, pass minimum accessibility or usability criteria. d. Work to resolve technical problems for on premise, cloud native, and hybrid applications and solutions. e. Support the gathering of information, necessary research needed for root cause analysis, problem definition and formulation, solution implementation, verification, and ongoing optimization. Provide analysis of defects to find root cause. f. Provide recommended solution(s) that promote successful delivery of business project objectives or production support objectives and support benefits realization. g. Identify issues and think through challenges in the form of options and solutions. Partner with others to identify resolutions to known issues, impacts to project or production outcomes if not resolved, and determine when to escalate when necessary. h. Communicate and provide regular updates and key information in a timely manner to leadership as well as the appropriate stakeholder audience. Collaborate and work as a team to accomplish goals and/or solve problems. i. Other duties as assigned. All your information will be kept confidential according to EEO guidelines. 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 [email protected] Please inform us if you meet the definition of a "Covered DoD official". At this time, Wellmark is not considering applicants for this position that require any type of immigration sponsorship (additional work authorization or permanent work authorization) now or in the future to work in the United States. This includes, but IS NOT LIMITED TO: F1-OPT, F1-CPT, H-1B, TN, L-1, J-1, etc. For additional information around work authorization needs please refer to the following resources:Nonimmigrant Workers and Green Card for Employment-Based Immigrants