Department: Compliance Oversight
Reports to: Manager, Compliance Oversight
Location: 8735 Henderson Road, Ren 2, Tampa FL 33634
WellCare has an immediate need for an experienced Clinical Delegation Oversight Auditor to join our team! This position participates in the oversight of WellCare’s and/or WellCare’s delegated vendor’s corporate ethics and compliance program, and the ongoing clinical oversight and analysis of regulatory compliance issues. Performs job responsibilities primarily through conducting clinically focused reviews, oversight and monitoring to assess compliance with WellCare’s contractual and regulatory requirements and collaborates with business owners and/or delegated vendors to drive remediation. Our ideal candidate will have experience managing 10-30 audits simultaneously in progress at various stages with our delegates. The incumbent will have a solid ability to maneuver through lots of moving parts while maintaining high documentation standards.
- Review and evaluate the effectiveness of corrective action plans and provide comprehensive follow-up to Senior Management, Market Compliance Oversight Committees, and/or the Regulatory Compliance Committee of the Board of Directors.
- Assist in the assessment of all new and amended Government contracts.
- Evaluate the effectiveness of market, shared services, and/or delegated vendor compliance programs and related policies and procedures designed to promote legal and ethical compliance.
- Clinically reviews and collaborates with other departments and/or delegated vendors to direct compliance issues to appropriate channels for investigation and resolution.
- Assist in the identification and assessment of compliance risks in market, shared services, and/or delegated vendors.
- Assist in the performance of the Ineligible Persons Process review and validation.
- Prepare accurate and timely formal written reports on oversight and monitoring activity findings and recommendations and ensuring that work papers are properly prepared in accordance with WellCare and Corporate Audit & Oversight standards and that sufficient evidentiary material exists to support oversight and monitoring activity findings.
- Participates in special projects as needed including training.
- This position serves to collaborate with and assist those within the Company and the Company’s delegated vendors to maintain integrity through oversight and monitoring and in meeting the requirements of our executed contracts with Government-sponsored health care programs.
- Performs other duties as assigned.
Required: Associate's Degree in Nursing, Pharmacy, or other Clinical related discipline and a Registered Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), or Licensed Clinical Social Worker (LCSW) designation.
Preferred: Bachelor's Degree in Nursing, Pharmacy, or other Clinical related discipline
- 3 years of experience in Managed Care/Health Insurance
- 1 year of experience in reading, analyzing and interpreting State and Federal laws, rules and regulations
- 1 year of experience in a project oversight type role with demonstrated ability to drive implementation and influence others
- Experience in State Medicaid or Federal managed care compliance
Licenses and Certifications:
One of the following is required:
- Licensed Registered Nurse (RN)
- Licensed Clinical Social Worker (LCSW)
- Licensed Vocational Nurse (LVN)
- Licensed Practical Nurse (LPN)
Demonstrate subject matter expertise in the area of Regulatory Compliance and Compliance Audit-related activities
Demonstrate self-motivation, initiative, practical learning skills, enthusiasm and an ability to complete multiple tasks in a timely and accurate manner
Ability to develop partnerships, teamwork and good working relationships
Understands the regulatory framework within which the Company operates
Good analytical skills and an understanding of operational processes and regulatory requirements
Demonstrated written communication skills
Demonstrated interpersonal /verbal communications skills
Ability to multi-task
Ability to work in a fast paced environment with changing priorities
Ability to effectively present information and respond to questions from families, members and providers
Knowledge of community, state and federal laws and resources
Demonstrated project management skills
Demonstrated ability to deal with confidential information
Demonstrated analytical skills
Proficiency in Microsoft Excel, Word, PowerPoint, Outlook, Access and Visio
Proficiency in Healthcare Management systems preferred