Full-Time
Quality Manager
Payment Integrity
Posted on 9/30/2025
Wellmark
1,001-5,000 employees
Health insurance for individuals and employers
No salary listed
Sioux Falls, SD, USA
In Person
Candidates must be licensed in the state in which they reside.
 Medical, Clinical & Veterinary (2) |
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- 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.
- Designing and executing a robust audit process for both clinical and non-clinical work performed by the Payment Integrity team.
- Auditing incoming and outgoing invoices.
- Managing ASO customer audits.
- Developing clear, scalable desk-level procedures and documentation that support operational excellence.
- Delivering quality review reports and surfacing trends that inform strategic decisions across the Payment Integrity function.
- Coaching peers on best practices, providing direct peer-to-peer feedback, and influencing others to uphold high quality standards.
- Collaborating closely with partners in Compliance, Audit, Operations, Network Relations, and beyond to ensure alignment and drive results.
- 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).
Wellmark provides health insurance in Iowa and South Dakota, offering plans for individuals, families, employers, healthcare providers, and insurance producers, including Medicare Advantage and Medicare Supplement options. Premiums from members pay medical claims and administrative costs, while the company also offers services such as health trend analysis and productivity resources for employers. It differentiates itself with a broad network, strong focus on customer satisfaction and service quality, and proactive solutions like new Medicare Advantage plans and COVID-19 cost waivers. Its goal is to deliver affordable, comprehensive coverage and support to people and businesses while upholding corporate responsibility and inclusivity.
Company Size
1,001-5,000
Company Stage
N/A
Total Funding
N/A
Headquarters
Des Moines, Iowa
Founded
1939
Simplify's Take
What believers are saying
- Evio investment leverages real-world evidence to cut pharmacy costs.
- Dr. Candice O’Sullivan as new MD drives innovative healthcare strategies.
- Iowa Rural Vitality Coalition boosts rural health and economic vitality.
What critics are saying
- CMS 2.3% Medicare Advantage cuts slash 2025 revenue immediately.
- UnitedHealth and Anthem capture 10-15% employer book in 24 months.
- Mutual structure blocks capital for AI claims tech versus competitors.
What makes Wellmark unique
- Wellmark dominates Iowa and South Dakota with over 50% market share.
- Invested in Evio Pharmacy Solutions March 6, 2025, for high-cost medication analytics.
- Hired Laura Jackson as EVP for Health Equity in February 2022.
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Benefits
Medical and prescription drug coverage
Dental coverage
Vision plan
Compensation: comprised of two components: base pay or annual salary, and potential pay from the Performance Incentive Program (PIP), awarded annually when financial and customer measures are successfully achieved.
Financial Benefits: competitive financial benefits through a generous 401(k) savings and investment plan.
Educational assistance
Pathways to Wellness incentives
Employee Assistance Program
Time off
Company News
Knoxville Community School District receives Grant from The Wellmark Foundation to bring new mental and Behavioral Health services to students. * Posted By: Clayton Sampson * January 15, 2026 @ 4:46 am * Today's Local News The Knoxville Community School District has received a grant from The Wellmark Foundation to bring new mental and behavioral health services to students. The Knoxville Community School District announced that beginning with the 2025-2026 school year, students will have access to in-person therapy and Classroom Clinic, a telehealth service that connects families, schools and mental health professionals to provide personalized mental and behavioral health support for students. "Thanks to the generous support of the Wellmark Foundation, our students will have expanded access to high-quality behavioral health services that meet them where they are - both in person at school and through telehealth," said Superintendent Cassi Pearson. " This grant allows us to strengthen proactive supports, build healthy habits, and equip students with the skills they need to manage challenges, succeed academically, and thrive both in and beyond the classroom." Classroom Clinic, a school-based telehealth company, collaborates with school districts to provide timely and convenient access to youth mental health care. Its services include telepsychiatry, provided by Psychiatric Nurse Practitioners, and teletherapy, from licensed mental health counselors. By introducing in-person therapy and Classroom Clinic, students at West and Northstar can access services for their mental and behavioral health similar to how they can visit the school nurse for physical health care. The new mental and behavioral health services are possible, in part, by a three-year School-Centered Behavioral Health Grant from The Wellmark Foundation. The Wellmark Foundation's School-Centered Behavioral Health Grant is available for eligible rural Iowa schools that want to establish lasting mental and behavioral health services for Iowa youth. For more information, visit Wellmark.com/SchoolBehavioralHealthGrant.
DENVER, March 6, 2025 /PRNewswire/ -- Evio Pharmacy Solutions proudly announces the addition of Wellmark Blue Cross and Blue Shield as its sixth investor and owner health plan. This new partnership is an exciting development for Evio as the company welcomes its first new investor since its establishment four years ago.Wellmark, a member-owned independent licensee of the Blue Cross Blue Shield Association, serves more than two million people in Iowa and South Dakota. Wellmark, known for its innovative approaches and commitment to making health care better, will further Evio's mission to deliver differentiated pharmacy care.Evio works with health plans to transform the medication experience for everyone: patients, providers, employers, and the pharmacy system at large. Utilizing real-world evidence analytics, innovative medication contracting models, and a suite of digital tools, Evio aims to ensure every patient can access the right medication for their unique situation, from the beginning, in a simple and affordable way."Our board and I are thrilled to welcome Wellmark to help drive our transformative agenda," said Hank Schlissberg, chief executive officer of Evio. "Having established a compelling vision, a phenomenal team, and a track record of measurable impact, Evio was open to new partners for the first time. When we evaluated potential additions, Wellmark quickly rose to the top
The Keep Iowa Beautiful Corporation Award goes to Wellmark for supporting community development efforts and collaboratively identifying challenges and opportunities for Iowa's rural communities.
The Dave Thomas Foundation for Adoption recently recognized Wellmark as one of the 100 best adoption-friendly workplaces in the U.S.
Wellmark was named Top Insurance Company in three Best of the Best lists and earned a five-star rating from the Centers for Medicare & Medicaid Services (CMS) for health plans, which rates providers for quality.