Clinical Operations Medical Review Supervisor (RN)

WPS Health Solutions - Madison, WI (30+ days ago)2.6

Who We Are

We are a leading not-for-profit health insurer in Wisconsin, and our services have grown to reach active-duty and retired military personnel, seniors, and families in Wisconsin, across the U.S., and around the world. Learn more!

WPS receives World's Most Ethical Company Award for 9th Year in a Row - 2018 Most Ethical Companies Announcement

At Our Core

WPS Health Solutions has earned a reputation as a leader in the insurance and benefits administration industry through our commitment to excellence and high-quality service. Our corporate values reflect the core of who we are and how we conduct business every day.

Customer Focused

I recognize how my actions impact internal and external customers by being responsible for the customer experience. I look beyond the immediate issue to recognize and solve the problem.

Individual Responsibility

I own my actions. I am accountable and dedicated to achieving the best results for WPS Health Solutions and our customers. I embrace my role in helping the company achieve a high-performance workplace.

Mutual Respect

I lead by example and act ethically, honestly and am trustworthy. I show appreciation for others by giving and taking constructive feedback and encouragement.

Driven and Passionate

I approach my work with enthusiasm, and personal commitment to the success of our business. I keep the importance of the work we do for our customers alive in my attitude and interactions with others, and demonstrate pride in the worthiness of our purpose.

Position Summary

This position is responsible for exemplifying and leading team in four core values of WPS: Mutual Respect, Customer-Focused, Individual Responsibility, and Driven and Passionate. You will recruit, develop, engage, and retain high-performing talent to meet current and future organizational needs. You will communicate and coach effectively and manage performance of individuals and team effectively to increase depth and flexibility of both.

In this role you will:
Provide Leadership and Coordination of Training/Development (90%)

Recruit, select, train, motivate, appraise job performance, and discipline employees.
Develop and execute employee engagement and achievement plans.
Coach and develop employees by focusing on competencies and individual performance.
Ensure operational tasks are completed by developing schedules, assigning and monitoring work, gathering resources, and implementing productivity and quality standards.
Ensure procedural and regulatory compliance for clinical decisions and activities as stipulated by Medicare program regulations and policy.
Ensure clinical-related decisions are rendered accurately and consistently by all clinicians.
Review and trend clinical errors to identify opportunities for additional training and need for clinical guidance or clarification.
Collaborate with Contractor Medical Director (CMD) to develop, revise, and administer medical policy.
Assist with internal and external audits.
Lead with the following values: o Mutual Respect: Lead by example and act ethically and honestly. Exemplify leadership by being credible, knowledgeable, and trustworthy. Carefully consider and respond to input and feedback, then implement changes to improve processes. Show appreciation for others by giving and taking constructive feedback and encouragement.
Customer Focused: Recognize impact of own actions on internal and external customers and be responsible for customer experience (timely and accurate responses, approachable, accessible). Look beyond immediate issue to recognize and solve root cause of problems. Simplify processes to improve results for customer.
Individual Responsibility: Take ownership of actions by being accountable and dedicated to achieving best results for WPS and customers. Be committed to improving job performance to achieve strategic goals (acquire and apply job knowledge and expertise). Take initiative and make decisions to address issues and take ownership to achieve better performance.
Driven & Passionate: Approach work with enthusiasm and personal commitment to success of business; sets high standards and continually raise bar. Bring energy and focus to achieve excellence and learn from mistakes. Actively participate in collaborative activities, engage in discussion, and offer own time and commitment. Help others achieve success by fostering individual and unique talents.
Oversee Financial Functions (10%)

Control expenses by monitoring variances to budget and identifying opportunities for efficiency.
Generate ideas for operating efficiencies.

You should have:
Bachelor’s degree in Nursing
Registered Nurse licensure applicable to the state of practice
4 years clinical nursing experience, including
1 year in a supervisory/leadership role
Experience responding to questions through verbal and written communication with
Experience with Medicare Providers; government agencies such as CMS (Centers for Medicare and Medicaid Services), GHA (Government Health Administrators); management staff, and other internal GHA departments and other Shared Services
Experience managing resolution of special handle and “unresolvable” claims, assisting in processing in difficult claim situations, and ensuring timely cooperation of external sources with submission of needed materials, medical records, and provider certification
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