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Corporate Functions & Operations WellCare - Clinical Compliance Careers

Clinical Delegation Oversight Auditor Job

Full Job Title: Clinical Delegation Oversight Auditor

Job Number: 1803078

Location: Tampa, FL

Date Posted: 2018-05-25

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.

Essential Functions:

  • 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.

    Education:

    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

    Work Experience:

    • 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)

    Skills:

    • 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

    Technical Skills:

    • Proficiency in Microsoft Excel, Word, PowerPoint, Outlook, Access and Visio
    • Proficiency in Healthcare Management systems preferred

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    Last Updated On: 12/9/2015