Health Services Quality Coach (Remote Eligible / RN Required)

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!

Full-time Department: Clinical | Health Networks | Provider Support Work Environment: Remote Eligible *see job footer for more info Pay Grade: 20 As an integral partner in upholding Wellmark’s compliance and consistency within utilization management and case management processes, you will be responsible for auditing the work of both clinical and non-clinical team members in support of Wellmark’s business portfolio, including FEP. Your primary focus will be to support internal and external performance metrics by auditing, researching, reporting, and analyzing Health Services activities to ensure alignment with established standards, policies, and procedures. Additionally, you will deliver individualized and group coaching to guide team members in achieving and surpassing company and FEP expectations and metrics. Serving as an expert in Wellmark’s clinical quality assurance review, you will identify and recommend improvements to Health Services procedures and ensure accurate documentation of processes. Building strong relationships and credibility within the organization will be critical to your success in this role. 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.

Assess and evaluate the accuracy of file documentation for complex Health Services processes; including appeal and secondary reviewer processes; phone calls and/or clinical and administrative documentation in accordance with business objectives and goals; identify documentation issues; identify best practices and provide effective solutions. Perform audits, research, and analysis to support department metrics targets, QA score expectations, and ensuring compliance with regulatory, accreditation, FEP and OPM requirements. Research issues identified in quality reviews by performing additional investigation into operational procedures, as well as communicating with the operating areas as needed. Assist in FEP UM and CM audits as needed. Generate reports and create documents that communicate results of analysis, research, and metrics to demonstrate trends, changes, and results of projects and activities. Use clinical knowledge to interpret results and make recommendations for process improvements and/or training needs. Generate and ensure accurate, timely reporting of quality measurements for leadership and business partners. Identify any procedural/documentation concerns, care team needs, and team or individual error trends to Health Services leadership. Report on trainee results and progression towards regular quality reviews. Collaborate with department leaders on individual or team performance or process improvement plans. Support the measurement of outcome and success metrics for Health Services. Collaborate with department trainer(s) in cross-training team members on procedures and guidelines for Health Services functions. Document and update quality review and procedural documents with edits and revisions as changes in guidelines or regulations occur. Proactively submit updates to Health Services processing documents. Serve as a business resource and subject matter expert (SME) for FEP process, reporting and letter requirements. Assist in investigation of quality of care, quality of service and department inquiry and complaints as needed. Participate in FEP pilots and/or projects as needed. Other duties as assigned.