Medical Director – Inpatient Utilization Management

About the Opportunity :   As an experienced M.D. or D.O. in adult acute care setting(s) you will use evidence-based decision making to perform inpatient case reviews that are timely and clinically appropriate. You will concisely effectively and consistently synthesize clinical information to document a clear summary of a medically necessary determination. While case reviews are this roles primary priority and function you will have the opportunity to make recommendations on efficiencies and innovations to ensure our members are getting appropriate and timely care based on their health plan coverage. You will partner across the organization with other internal teams such as Business Analytics Claims Operations Actuarial and BlueCard to name a few. Join us on this continuous journey as we make health care better for our members!

About You :  You are decisive and have a strong ability to influence internally and externally by appropriately and effectively presenting evidence-based medicine to support a determination. Critical thinking sound judgment and decisiveness are key; however you will be able to draw from your colleagues subject matter expertise from various departments to help make evidence-based prior authorization decisions. You are collaborative by nature and are energized by the opportunity to work in a highly integrated and matrixed culture.  Managed care experience in a large commercial organization such as at another Blue Cross & Blue Shield plan a plus.

If this sounds like you apply to our Medical Director-Inpatient Utilization Management opportunity today!

Iowa or South Dakota-based candidates preferred but open to remote for the right candidate.

This full-time position will also work a rotating on-call schedule for weekend and holiday reviews.

Qualifications :

Required Qualifications - Must have :

• Graduate of an accredited medical school; M.D. or D.O. degree is required.
• Active and unrestricted license to practice medicine in Iowa or Iowa Administrative Medical License is required within 3 months from date of hire AND must be licensed in the state in which you reside. While obtaining license the incumbent will participate in training provide operational guidance and advice and participate in projects as assigned while licensure is pending approval.
• Current Board Certification in Emergency Medicine Family Medicine or Internal Medicine through the American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA).
• 3-5 years of adult inpatient clinical experience in an acute care hospital setting (e.g. inpatient unit or emergency department) sufficient to enable medical judgments regarding appropriateness of inpatient care medical necessity and post-acute care.
• Ability to participate in rotating on call schedule for weekends and holiday reviews.
• Strong analytical and critical thinking skills; makes sound evidence-based decisions.
• Demonstrated commitment to service excellence (timeliness accuracy quality) and advocacy for member care.
• Strong consulting and interpersonal skills. Quickly builds rapport and establishes credibility.
• Excellent verbal and written communication skills. Ability to communicate effectively and with clarity with internal and external audiences and clinical peers even when conveying difficult decisions and complex information.
• Strong change management skills. Creates a clear view of future state and inspires others to advance the vision.
• Ability to mentor and guide others and work within the teams. This includes sharing accountability influencing without direct authority and effectively listening to others.
• Self-starter with strong organization and time management skills. Flexible with changing priorities.
• Works well independently and collaborates as a member of a cross-functional team; ability to navigate in a dynamic corporate environment.
• Strong technical acumen. Learns new systems and processes quickly (e.g. Microsoft Office clinical platforms etc.).

Preferred Qualifications - Great to have :

Additional Information :

What you will do as a Medical Director for Inpatient Utilization Management (UM) :

a. Demonstrate ability to apply clinical experience in the care of patients in an acute care hospital setting to render medical necessity determinations for adult acute inpatient care. The foundation for Wellmarks definition of medical necessity is Evidence-Based Medicine and evidence of sound clinical reasoning.

b. Concisely effectively and consistently synthesize clinical information to document a clear summary for the basis of medical necessity determinations. The documentation in the UM record will reflect the ability to act timely and decisively based on the clinical records that were submitted to support the medical necessity for inpatient level of care.

c. Develop an effective and collaborative relationship with Wellmarks UM leaders to continually improve the end-to-end UM process by providing ideas and feedback on improvement. Actively identify opportunities for process improvement or the need for new processes that are observed in the course of day-to-day work. Demonstrates openness to receiving and acting on constructive feedback.

d. Defend UM decisions internally and externally using evidence-based medicine sound clinical reasoning and critical thinking skills. Actively listen for relevant new information and compelling counterarguments. Revise decision when the fact basis requires it.

e. Demonstrate sound judgment by seeking consultation from leader on complex UM case reviews.

f. Effectively engage in peer-to-peer calls. Seek to understand new information that the provider may offer. Effectively and concisely uphold the UM decision or revise the UM decision based on new information when necessary.

g. Perform overflow Outpatient reviews as needed.

h. Deep knowledge of and proficiency in applying Wellmarks medical policies especially for commonly requested outpatient services.

i. Participate in rotating on call schedule for weekend and holiday reviews.

j. Other duties as assigned.

This job requires a non-compete agreement.

An Equal Opportunity Employer

The policy of Wellmark Blue Cross Blue Shield is to recruit hire train and promote individuals in all job classifications without regard to race color religion sex national origin age veteran status disability sexual orientation gender identity or any other characteristic protected by law.

Applicants requiring a reasonable accommodation due to a disability at any stage of the employment application process should contact us at

Please inform us if you meet the definition of a Covered DoD official.

At this time Wellmark is not considering applicants for this position that require any type of immigration sponsorship (additional work authorization or permanent work authorization) now or in the future to work in the United States. This includes but IS NOT LIMITED TO : F1-OPT F1-CPT H-1B TN L-1 J-1 etc. For additional information around work authorization needs please refer to the following resources : Nonimmigrant Workers and Green Card for Employment-Based Immigrants

Remote Work : Yes

Employment Type : Full-time

Key Skills

EMR Systems,Post Residency Experience,Occupational Health Experience,Clinical Research,Managed Care,Primary Care Experience,Medical Management,Utilization Management,Clinical Development,Clinical Trials,Leadership Experience,Medicare

Experience : years

Vacancy : 1