Quality Manager Payment Integrity (Medical Coding Certification Required)

Job description

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.

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.

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 additional investigation as necessary to drive consistency and accuracy.



e.

Develop and monitor corrective action plans for any identified audit issue, including partnering with Wellmark’s Compliance team on any issue resolutions that may be necessary.



f.

Establish and maintain positive team member relationships and provide mentoring and coaching performance by providing quality assurance feedback and subject matter.



g.

Lead project and process improvement initiatives, when appropriate.



h.

Share and encourage ideas and collaborate with the team to create efficiencies in work processes and efforts.



i.

Comply with regulatory standards, accreditation standards and internal guidelines; remain current and consistent with the standards pertinent to the payment integrity and Network team.



j.

Alert Wellmark’s internal Compliance team of any variances that need to be documented and addressed at the corporate level and partner with this team to resolve variances.



k.

Other duties as assigned.

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 .

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: and  

Required Skill Profession

Operations Specialties Managers