at WPS Health Solutions in Marion, Illinois, United States
Job Description
Description
Who We Are
is a leading not-for-profit health insurer in Wisconsin. Our services offer health insurance plans for individuals, families, seniors, and group plans for small to large businesses. We process claims and provide customer service support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. In 2021, WPS Health Solutions celebrated of making health insurance easier for those we serve. Proud to be military and veteran ready.
Our Culture
WPS' Performance-Based Culture is where the great work and innovations of our people are seen, fueled, and rewarded. We accomplish this by creating an inclusive, empowering employee experience, focusing on People, Work, and Conditions. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities. We are guided by our Purpose: Together, making health care easier for the people we serve.
In 2021, 2022, and 2023, WPS Health Solutions was recognized for several awards including:
Role Snapshot
The part-time Medical Director will work on the Medical Management team in our WPS Health Insurance line of business. This role will oversee the process to ensure the appropriateness and quality of medical care provided to our members. In addition, the Medical Director will actively use their medical background, experience, and judgement, with available evidence-based sources make determinations whether requested services, requested level of care, and/or requested site of service should be authorized. This position is an individual contributor role and reports to the Vice President of Operations and Medical Management.
The Medical Management department's overall purpose is to improve the health of the individuals we serve by offering efficient, high-quality, customer-centric medical management services that will also lower the cost of the claims. WPS designed the Integrated Care Management (ICM) Program to demonstrate accountability to the Plan's customers and employer groups, through active monitoring and managing of healthcare resources across the full continuum of care.
Specific position responsibilities will include:
Participate collaboratively with the Sales Team for on-site visits to potential group clients, for presentations regarding Requests for Proposals (RFP) as well as group renewals.
Perform pre, post, and concurrent utilization review determinations.
Support policy development using evidence-based criteria.
Work with Medical Coder to review new CPT and HCPS code as they are released quarterly.
Produce a "Doctors Note" quarterly that will be included in the provider newsletter.
Participate in reviews of how members plan documents/coverage is formed.
Serve as Clinical Advisor for Integrated Care Management and Case Management.
Perform peer to peer requirements for discussing cases with medical providers.
Provide support to the nursing staff which includes assisting in staff training to ensure consistency in applying policy criteria and educate regarding new procedures, including services and changes in certificate language.
Serve on Grievance and Appeals Committee (provider or member) as Medical Advisor which includes OCI complaints and IRO reviews.
Member and/or Moderator of the following committees:
Medical Policy Committee
Credentialing Committee
CPPC (Clinical Policy and Process Committee) Committee
UM (Utilization Management) Rounds Committee
Quality Improvement Committees for health plans and other committees as assigned
How do I know this opportunity is right for me? If you:
Have strong utilization management experience.
You communicate with confidence, clarity, and sound reasoning when discussing concerns, ideas, and suggestions with all levels of staff and management.
Are humble and collaborative in your approach to work.
What will I gain from this role?
Working on a Medical Management team that far exceeds URAC and NCQA standards.
The ability to make healthcare easier for those we serve in our WPS Health Insurance line of business.
There might be an opportunity in the future for this role to become full-time in the future.
Experience working in an environment that serves our Nation's military, veterans, Guard and Reserves and Medicare beneficiaries.
Minimum Qualifications
5 or more years working as a practicing physician with strong utilization management experience including conducting pre, post, and concurrent utilization review determinations, peer to peer reviews, understanding medical policy criteria and working with a team of nurses and physicians to apply the criteria.
Board certified doctor of medicine or of osteopathic... For full info follow application link.
Wisconsin Physicians Service Insurance Corporation is an Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities employer.
