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WPS Health Solutions is a leading not-for-profit health insurer and federal government contractor headquartered in Wisconsin. WPS offers health insurance plans for individuals, families, seniors, and group health plans for small to large businesses. We process claims and provide customer 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. WPS Health Solutions has been making health care easier for the people we serve for more than 75 years. Proud to be military and veteran ready.
Culture Drives Our Success
WPS’ Culture is where the great work and innovations of our people are seen, fueled, and rewarded. We accomplish this by creating an inclusive and empowering employee experience. We recognize the benefits of Diversity, Equity, and Inclusion as an investment in our workforce—both current and future—to effectively seek, leverage, and include diverse perspectives that fuel agility and innovation on high-performing teams. 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 proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition
Role Snapshot
The 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.
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.
Experience working in an environment that serves our Nation’s military, veterans, Guard and Reserves and Medicare beneficiaries.
Minimum Qualifications
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 medicine, with a valid medical license in the State of Wisconsin, and no federal sanctions
5 or more years working as a practicing physician.
Requires strong analytical, problem-solving, communication (both written and oral), teamwork, and organizational skills.
Ability to speak in front of employer groups and demonstrate the value of our medical management services and products and willingness to collaborate with other health care providers/systems.
Ability to travel with our sales team to RFP group presentations anywhere in Wisconsin (typically day trips).
Experience using MS Teams and Outlook.
Please note: The work performed in this role cannot be performed outside of the United States.
Preferred Qualifications
Familiar with Wisconsin Care Systems.
Familiar with medical criteria tools (e.g., MCG, InterQual).
Able to demonstrate a collaborative mindset.
Pay
$260,000-$300,000
The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, experience, and may fall outside of this range.
Work Schedule
This position is full time opportunity between the core business hours of 8:00 AM to 4:30 PM.
Work Location
We are a remote-first organization and offer remote work in the following approved states:
Arizona, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, North Carolina, North Dakota, Ohio, South Carolina, South Dakota, Texas, Virginia, Wisconsin
Remote Work Requirements
High speed cable or fiber internet
Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net)
Please review Remote Worker FAQs for additional information