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Wellmark - Des Moines Director of Payment Integrity in Des Moines, Iowa

Use your strengths as Wellmark's new Director of Payment Integrity

With a focus on the member experience, Wellmark's Director of Payment Integrity will provide strategic oversight, leadership, and technical expertise to a professional staff responsible for driving overall leading practice in analysis, evaluation, process improvement, recommendation and development of strategic plans that align with the future vision of a Payment Integrity initiative. This individual will partner with a Governance/Steering Committee, executive leadership, and cross-functionally to facilitate accurate claims payments according to contractual terms across Wellmark; this includes ensuring all payments are made through the right benefit program, to the right provider, for the appropriate services free of wasteful or abusive practices.

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.

Ideal candidates must demonstrate strong business acumen and an engineering mindset to effectively understand and connect the different pieces of a complex business and associated processes. They are skilled at thinking up and downstream, leveraging their industry-specific business acumen – specifically beginning when services are rendered to when they are accurately paid – to identify interdependencies and the appropriate contingency plans. Ideal candidates are also effective change agents and advocates who actively share vision and rally others to come along for the journey. They're respected for their expertise and appreciated for their approach, which is centered on leveraging valuable partnerships with others to achieve results.

Required:

  • Bachelor’s degree in business, health care administration or related field, or direct and equivalent work experience.

  • 7+ years of health care, health plan or related experience that includes 4+ years of progressively responsible experience in various functions of payment integrity - e.g., claims editing, coordination of benefits, overpayment identification, claims auditing, fraud, health care subrogation/third party liability, etc.

  • Track record of success leading enterprise-wide programs/projects. Effective decision making, strategic planning, and resource management.

  • Demonstrated leadership experience with success developing high performing teams. Establishes clear goals/expectations and motivates teams to achieve success.

  • Skilled in designing, developing, and implementing process structure, tools, and measurement indicators that drive operational results.

  • Familiarity with claim payment methodologies, professional and facility coding, billing software/analytics platforms, etc.

  • Analytical with the ability to synthesize complex data/information into relevant, actionable recommendations; uses data to inform decisions, thinks critically and demonstrates effective problem solving skills.

  • Continuous improvement-focused; identifies opportunities for optimization, defines savings/cost reductions, and oversees implementation.

  • Exceptionally strong facilitator and communicator with executive presence. Effectively delivers a variety of messages to diverse audiences, including board presentations.

  • Develops collaborative relationships with executives, stakeholders, operational teams, and vendor partners. Builds trust, influences decisions, negotiates, and resolves conflict to achieve business results.

  • Forward thinking, proactive, and a thoughtful approach to initiative prioritization; skilled at moving from strategy into tactics and execution.

  • Strong change management skills. Creates a clear view of future state and inspires others to embrace and advance the strategy.

  • Travel required up to 5%.

Preferred:

  • Master’s degree in business or health care administration.

  • Experience working in the payment integrity field or within a payment integrity office.

  • Extensive knowledge of Medicare/Medicaid health-care regulations, legislation/laws, or in-depth operational experience of medical billing, coding and provider claims processing and adjustment.

  • Financial management experience.

a. Provide the strategic direction and leadership to a team of payment integrity professionals, and several highly matrixed subject matter experts that support Wellmark and divisional strategy and goals and maintain a sustainable competitive advantage. Cascade and communicate strategy and initiatives to team members, driving customer/stakeholder service, and supporting achievement of overall company results.

b. Team Leadership: 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 staff, and department specific functions/services e.g. initially Prepay/Claims editing team.

c. Payment Integrity Ideation and Business Planning: In strategic partnership with a Governance/Steering Committee and executive leadership, facilitate process for development of vision, goals, and strategic plans for Payment Integrity Office. Establish and manage processes and leading practice around an enterprise wide Payment Integrity initiative. Responsible for determining the appropriate strategy, service level agreements and functionality and will implement this strategy across a complex business model.

d. Project Management/Prioritization: Responsible for compiling and prioritizing outputs of ideation discussions formulating business plan for deployment of solutions, including alternative approaches, identification of impact to vendor solutions and internal processes, and preparing proposal for review and approval by Steering Committee and/or senior leadership. Serve as sponsor/lead for approved projects and payment integrity initiatives, as applicable. Provide oversight to key business partners in support of other cross functional initiatives. Monitor project plan results, adjusting plans and performance expectations to achieve targeted results.

e. Team/Cross Functional Leadership: Lead and direct the work of payment integrity office team, and provide oversight and direction to highly matrixed teams, collaborating with business process execution teams and project teams to break down silos that limit payment integrity efficiencies while balancing business process operational needs. Ensure payment integrity strategy and initiatives have been cascaded and communicated to cross functional teams. Partner with key departments and teams in the development, formulation, recommendation, and implementation of decisions regarding policy, standards, methods, procedures, and functions as it relates to Payment Integrity.

f. Enterprise-wide Collaboration: 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.

g. Measurement and Reporting: Drive payment integrity measurement consistency, tracking, reporting, and inputs to inform future enhancement opportunities and insight development across divisions, cross functional teams, and processes. Utilize extensive understanding of payment integrity metrics and leading practices for process improvement and creation of intuitive dashboard analysis platform. Prepare and present on the progress of Payment Integrity capability building, including identification of trends, key performance indicators, and overall program health.

h. Process/Continuous Improvement: Lead efforts in enterprise wide facilitation and identification of process improvements that support the h. Payment Integrity initiative. Responsible for development and oversight of payment integrity inventory tracking and forecasting tools. Monitor the advancements in payment integrity technology and trends, predictive analytics, and the use of machine learning in order to drive automation, efficiencies, and effectiveness advancements within Payment Integrity.

i. Vendor Management: Oversee multiple Payment Integrity vendor relationships and performance. Lead weekly, monthly, and quarterly business review meetings with vendors and executive management as appropriate. Identifies emerging vendor capabilities that optimize cost containment actions. Direct cost benefit analysis to determine if any functions should be internal or outsourced.

j. Regulatory/Compliance: 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.

Requisition ID: 214323

REQUIRES NON-COMPETE?: Yes

External Company Name: Wellmark Blue Cross and Blue Shield

External Company URL: www.wellmark.com

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