Medical Director Responsible for clinical direction of medical services and quality improvement functions at the health plan. Provides medical management leadership and, as applicable, manages all major clinical and quality program components under health plan operations. Oversees medical coordination required for effective utilization and quality management of the health plan network. Functions as medical leadership for effective care integration of pharmacy operations, utilization, case, and disease management activities, quality management activities, and provider relations functions. Doctor of Medicine (MD) or D.O. from an accredited school of medicine recognized by national medical regulatory bodies in the United States An unrestricted and current license to practice medicine in Iowa Board certification Direct patient care experience Substantial experience and expertise in the development of medical policies, procedures and programs Demonstrated success implementing utilization and quality improvement strategies and experience with physician behavior modification 5 Des Moines, IA Vice President, Field Health Services Accountable for quality improvement, utilization management, pharmacy behavioral health, care, and care coordination functions. Responsible for oversight and direction of WellCare of Iowa’s day-to-day activity related to clinical care coordination for our members. Bachelor’s Degree in Nursing Unrestricted and current license in Iowa Managed care experience Experience with leadership and management , preferably in a managed care environment Demonstrated expertise in Health Services, such as prior authorization, intake, concurrent review, case management, discharge planning including development and management of government programs 10 Des Moines, IA
Grievance & Appeals Manager Manages and coordinates grievance and appeals program monitoring and compliance testing for the Health Services, Quality and Market functions. Responsible for the closure of corrective actions and process improvements activities. Plans and directs activities within appeals and grievances including audits and Administrative Law Judge (ALJ) hearings. Bachelor's Degree in Health Administration, Business, Nursing, or related field Required Grievance and appeals experience related to compliance, regulatory, claims, and/or provider services Experience in the health care industry 5 Des Moines, IA Quality Management Manager (Director, Quality Improvement) Plans, develops and directs the Quality Improvement functions. Accountable for QI project managers and clinical practice advisors dedicated to improvement of targeted HEDIS measures, along with preparation for of WellCare of Iowa. Ensures compliance with state, federal and accreditation requirements. Iowa license (physician, physician’s assistant, or nurse) or relevant certification (i.e., CPHQ, NAHQ) Bachelor’s Degree in HealthCare, Nursing, Public Health, Health Administration or related field Direct experience with Quality Improvement job functions Managed care experience Experience with accreditation 7 Des Moines, IA
Utilization Management Manager (Director, Utilization Management) Accountable for providing vision and strategy for inpatient utilization and prior authorization management activities designed to achieve quality and service-driven objectives. Oversees all phases of development, organization, planning and implementation of operations and projects to enhance quality-driven outcomes. Accountable for a team of Iowa-based UM nurses. Leverages review criteria and guidelines working in partnership with the prior authorization team in Tampa. Oversees onsite concurrent review in participating hospitals. Bachelor’s Degree in Nursing, Health Administration, Nutrition or related field Unrestricted and current license in Iowa Acute clinical or surgical experience and/or behavioral health clinical setting Managed care experience Experience in utilization management to include pre-authorization, utilization review, concurrent review, discharge planning, and/or skilled nursing facility reviews 7 Des Moines, IA Care Coordination Manager (Director, Case Management) Accountable for team of community-based case managers tasked the full scope of case management, along with a team of field service coordinators responsible for day-to-day care coordination. Bachelor’s Degree in Nursing or Health Administration Registered Nurse Clinical Specialist (RNCS) Case management experience Managed care experience Management experience 7 Des Moines, IA Behavioral Health Manager (Senior Manager, Behavioral Care) Accountable for team of behavioral health specialists. Works with the Case Management team to ensure that care is integrated into each care plan. Master's Degree in clinical social work, psychology, counseling, or rehabilitation (if LSCW) Experience with direct patient care Clinical behavioral health services experience Utilization management experience 3 Des Moines, IA
Member Services Manager (Manager, Member Services and Relations) Responsible for oversight of member services functions including helpline telephone performance, e-mail communications, member education, the member website, member outreach programs, and development, approval and distribution of member materials. Bachelor’s Degree or equivalent relevant work experience Experience with social service-type activities preferably "grass roots" efforts 5 Des Moines, IA Provider Services Manager Manages multiple vendor partners for provider service performance from initial launch of services through day-to-day interactions. Accountable for management standards and financial responsibility. Call center and/or managed healthcare operations experience Vendors management experience across multiple markets and geographies Proven process improvement and project management experience Comprehensive knowledge of Medicare/ Medicaid government programs 5 Tampa, FL Information Systems Manager (Director, State Information Technology and Operations) Serves as the chief liaison for corporate operations to the state president. Serves as an ambassador/liaison for WellCare with various state agencies. Acts as a liaison for Regulatory issues surrounding any Operations area, including Claims, Call Center, Enrollment, etc. Experience in Health Plan Operations Experience in IT management or Systems A Bachelor's Degree in a related field or equivalent work experience 3 Des Moines, IA Claims Administrator (Senior Director, Claims) Responsible for the strategic direction, department leadership and the processing activities of the claims department in support of established production and quality standards. Bachelor’s Degree or equivalent work experience in claims administration or related field Managed care claims processing management experience 10 Tampa, FL