CIU Investigator

The CIU Investigator investigates and remediates compliance and sales & marketing related matters deemed to be of moderate to high complexity. Supports and leads complex investigations and prepares and reviews internal and external reporting. Supports the Senior Manager, Compliance Investigations in the day-to-day Corporate Compliance functions under WellCare's Corporate Compliance Program.

Essential Functions:
  • Independently evaluates and assesses allegations to determine those criteria, including federal and state regulations, Centers for Medicare & Medicaid Services (“CMS”) guidelines, and internal policies, procedures, and standards that are alleged to have been violated.
  • Prepares and analyzes Company and departmental metrics including, but not limited to, Sales & Marketing activities, internal investigations and makes recommendations accordingly. Prepares presentations for departmental and business management and other stakeholders.
  • Conducts and documents interviews with beneficiaries, sales agents, providers, associates, and/or downstream entities as required for investigatory purposes.
  • Identifies risks, interprets investigation results, and recommends and communicates remedial actions to mitigate future potential risks.
  • Plans, develops, and leads multiple projects, including prioritizing and managing through execution. Thoroughly documents, organizes, and reviews case files, electronic and hardcopy, relative to each investigation in accordance with Company policy and ensures remediation activities are tracked and implemented. Provides support and guidance to junior investigative staff as applicable.
  • Prepares clear and concise draft investigative plans and reports. Provides support and guidance to junior investigative staff as applicable.
  • Attends business meetings with various business area managers.
  • Supports the development and maintenance of Corporate Compliance policies and procedures and workflows.
  • Performs other duties as assigned.
Additional Responsibilities:
    Candidate Education:
    • Required A Bachelor's Degree in a related field or equivalent combination of education and experience
    Candidate Experience:
    • Required 3 years of experience in Investigations, auditing and risk analysis
    • Experience in reading, analyzing and interpreting State and Federal laws, rules and regulations
    • Previous State or Federal managed care compliance experience or certification in related field CFE, Certified Fraud Examiner
    Candidate Skills:
    • Experience in reading, analyzing and interpreting State and Federal laws, rules and regulations
    • Ability to communicate and make recommendations to upper management
    • Ability to effectively present information and respond to questions from families, members, and providers
    • Ability to effectively present information and respond to questions from peers and management
    • Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
    • Ability to represent the company with external constituents
    • Ability to influence internal and external constituents
    • Demonstrated ability to deal with confidential information
    • Demonstrated problem solving skills
    • Knowledge of community, state and federal laws and resources
    • Knowledge of healthcare delivery
    Technical Skills:
    • Preferred Intermediate Other Knowledge and understanding of claims processing systems and medical claims coding preferred
    • Preferred Intermediate Other Computer literate (MS Office, Excel, etc.)

      About us
      Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. WellCare is a Fortune 500 company, and in 2018, was recognized as a Fortune "World's Most Admired Company", ranking in the top five among the health insurance and managed care industry-a testament to the hard work and dedication of the company's nearly 9,000 associates who each day live WellCare's values and deliver on its mission to help its members live better, healthier lives. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. For more information about WellCare, please visit the company's website at EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.