Quality Manager - Payment Integrity (Medical Coding Certification Required)

Company Description

Why Wellmark: 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! 

Learn more about our unique benefit offerings here. 

Job Description

Use your strengths at Wellmark as a Quality Manager for Payment Integrity!   

In this newly created and high-impact role, you’ll take the lead in designing and executing a robust audit process for both clinical and non-clinical work performed by the Payment Integrity team. Your responsibilities will include auditing incoming and outgoing invoices, managing ASO customer audits, and developing clear, scalable desk-level procedures and documentation that support operational excellence.

You’ll also play a pivotal role in delivering quality review reports and surfacing trends that inform strategic decisions across the Payment Integrity function. Your insights will directly influence process improvements and help shape the future of quality assurance within the team.

While this is not a people-leader role, it requires strong leadership qualities and confidence in your coding experience. You’ll need to build trust and credibility across teams, coach peers on best practices, provide direct peer-to-peer feedback, and influence others to uphold high quality standards. Collaboration is essential—you’ll work closely with partners in Compliance, Audit, Operations, Network Relations, and beyond to ensure alignment and drive results.

Qualifications

Preferred Qualifications - Great to have:

• Active and Unrestricted Licensed Practical Nurse (LPN) or Registered Nurse (RN) license in Iowa or South Dakota (individual must be licensed in the state in which they reside).

Required Qualifications - Must have:

• Associate degree or direct and applicable work experience.
• Coding certification- e.g., CPC, CPC-P, COC, CCS-P, RHIT, or RHIA.
• 4+ years of work experience in payment integrity, SIU, insurance operations, coding, claim processing, contracting, credentialing. medical policy, or similar areas.
• 2+ years of work experience completing audits or coordinating audits.
• Strong ability to coach and mentor others with regards to audit results.
• Excellent analytical, research, and critical thinking skills, demonstrating the ability to review, analyze, and interpret regulations and other guidelines and provide insights or recommendations.
• Ability to effectively evaluate data/trends, solve practical problems, and conduct audits and research as needed.
• Quality assurance and process improvement mindset.
• Effectively manages competing priorities in a fast-paced, dynamic work environment. Flexible and adaptable to changing priorities is a must.
• Ability to measure and evaluate work processes and utilize appropriate resources to identify opportunities or implement solutions.
• Ability to build relationship and consult with stakeholders, apply subject matter expertise and influence decisions appropriately.
• Proficient with Microsoft Office (e.g., Word, Excel, Outlook) and web-based applications (e.g., PolicyTech), with the ability to learn new technology quickly.

Additional Information

What you will do as a Quality Manager for Payment Integrity:

a. Develop and manage multiple audit projects including work done by clinical and non-clinical team members, incoming and outgoing InterPlan invoices, and third-party audits requested by ASO groups (both Wellmark and non-Wellmark groups) in which payment integrity functions have been performed.

b. Provide timely and accurate information regarding procedural/documentation concerns, team needs, and error trends to the payment integrity leadership team. Information provided will include team and individual contributor quality reports shared with leaders regarding quality results, error trends, and issues that must be addressed, including reporting on trainee results and progression towards regular quality reviews.

c. Compile and maintain audit documentation to support audit work performed, issues and conclusions identified and recommendations/action plans. Create desk-level audit procedures, as necessary.

d. Lead, collaborate and consult with business unit leaders by researching issues identified in quality reviews by performing additi