Utilization review nurse Jobs in Cedar Rapids, IA

If not within a commutable distance to a Wellmark office 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 within driving distance or a direct flight to Des Moines Iowa are preferred. Central Time Zone 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 members strengths and fostering a team-centric work environment. Being a role model in behaviors that demonstrate   Wellmarks 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 Wellmarks 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 Wellmarks 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 :

Required Qualifications - Must have :

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 Wellmarks 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 Wellmarks 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 Wellmarks UM program.

f. Responsible for oversight of delegated specialty UM vendor clinical decision-making. Audit UM decisions to ensure compliance with Wellmarks 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 Wellmarks 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

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

Remote Work : Yes

Employment Type : Full-time

Key Skills

EMR Systems,Post Residency Experience,Occupational Health Experience,Clinical Research,Managed Care,Primary Care Experience,Medical Management,Utilization Management,Clinical Development,Clinical Trials,Leadership Experience,Medicare

Experience : years

Vacancy : 1