Wellmark, Inc., a mutual insurance company owned by its policyholders across Iowa and South Dakota, is seeking a Health Services Quality Coach. In this role, you will be an integral partner in upholding compliance and consistency within utilization management and case management processes. You will support internal and external performance metrics by auditing, researching, reporting, and analyzing Health Services activities to ensure alignment with established standards, policies, and procedures.
What You'll Do
- Assess and evaluate the accuracy of file documentation for complex Health Services processes, including appeals and secondary reviews, to identify issues, best practices, and provide solutions.
- Perform audits, research, and analysis to support department metrics, quality assurance scores, and ensure compliance with regulatory, accreditation, FEP, and OPM requirements.
- Research issues identified in quality reviews by investigating operational procedures and communicating with operating areas. Assist in FEP utilization and case management audits as needed.
- Generate reports and documents that communicate analysis results and metrics to demonstrate trends and project outcomes. Use clinical knowledge to recommend process improvements and training needs.
- Ensure accurate, timely reporting of quality measurements to leadership, identifying procedural concerns, care team needs, and error trends. Report on trainee progress.
- Collaborate with department leaders on individual, team, or process improvement plans.
- Support the measurement of outcome and success metrics for Health Services.
- Collaborate with department trainers to cross-train team members on Health Services procedures and guidelines.
- Document and update quality review and procedural documents as guidelines or regulations change.
- Serve as a business resource and subject matter expert for FEP processes, reporting, and letter requirements.
- Assist in investigating quality of care, quality of service, and department inquiries and complaints as needed.
- Participate in FEP pilots and projects as needed.
What We're Looking For
- Completion of an accredited registered nursing program.
- Active and Unrestricted Registered Nurse (RN) license in Iowa or South Dakota (must be licensed in your state of residence).
- 4+ years of clinical or equivalent industry experience, including exposure to complex operational processes or health services quality reviews with the ability to evaluate, coach, and mentor others.
- Strong communication skills to articulate complex, technical information verbally and in writing.
- Demonstrated ability to establish and maintain positive relations with colleagues, stakeholders, and customers, with the ability to influence others and promote collaboration.
- Analytical skills to evaluate data and trends, solve practical problems, and conduct audits and research. A quality assurance and process improvement mindset.
- Experience with computer software applications like the Microsoft Office Suite, electronic charting, and documentation systems. Technical aptitude to learn new systems.
Nice to Have
- Interrater Reliability (IRR) certification.
- Quality assurance and coaching experience, and/or health plan experience.
- Prior remote work experience.
- Candidates located in Iowa or South Dakota are preferred.
Technical Stack
- Microsoft Office Suite
- Electronic charting systems
- Documentation systems
Team & Environment
This role is within the Clinical | Health Networks | Provider Support department.
Work Mode
This position is eligible for hybrid work and is open to candidates residing in Iowa or South Dakota.
Wellmark Blue Cross Blue Shield is an equal opportunity employer. We recruit, hire, train and promote individuals without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or any other characteristic protected by law.
