Reports to: Sr Manager Compliance Oversight
The Compliance Oversight Specialist participates in the oversight of WellCare's and/or WellCare's delegated vendor's corporate ethics and compliance program, and the ongoing oversight and analysis of regulatory compliance issues. The Compliance Oversight Specialist performs job responsibilities primarily through conducting 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.
Additional Responsibilities:Candidate Education:
- 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.
- 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 A Bachelor's Degree in a related field or 4 years equivalent work experience in Health Plan Operations, Shared Services Operations (Claims, Appeals, Grievances, Customer Service, Credentialing, Network Management, etc.), and/or Compliance Program
- Required 3 years of experience in Managed Care/Health Insurance
- Required 1 year of experience in reading, analyzing, and interpreting State and Federal laws, rules and regulations
- Required Other Experience in State Medicaid or Federal managed care compliance
- Required 2 years of experience in a project oversight type role with demonstrated ability to drive implementation and influence others
Licenses and Certifications:
- Intermediate Knowledge of community, state and federal laws and resources
- Intermediate Demonstrated project management skills
- Intermediate Demonstrated ability to deal with confidential information •Maintains a high degree of credibility, independence, integrity, confidentiality and trust
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Ability to effectively present information and respond to questions from peers and management
- Intermediate Demonstrated analytical skills
- Intermediate Ability to work in a fast paced environment with changing priorities •Ability to operate successfully in a constantly changing, fast-paced environment
- Intermediate Demonstrated written communication skills •Strong writing, communication, and presentation skills
- Intermediate Other Good analytical skills and an understanding of operational processes and regulatory requirements
- Intermediate Other Understands the regulatory framework within which the Company operates
- Intermediate Other Ability to develop partnerships, teamwork and good working relationships
- Intermediate Other Demonstrates self-motivation, initiative, practical learning skills, enthusiasm and an ability to complete multiple tasks in a timely and accurate manner
- Intermediate Other Demonstrate subject matter expertise in the area of Regulatory Compliance and Compliance Audit
A license in one of the following is required:
- Preferred Certified Internal Auditor (CIA)
- Preferred Certified Information Systems Auditor (CISA)
- Preferred Other Certified in HealthCare Compliance (CHC)
- Required Intermediate Microsoft Excel Knowledge of Microsoft Office tools including Microsoft Project, Power Point, Excel, Visio, and Access
- Required Intermediate Microsoft Access Previous experience managing compliance issues via audit/compliance platforms a plus
- Required Intermediate Microsoft PowerPoint Knowledge of Healthcare systems a plus
- Required Intermediate Microsoft Visio
- Required Intermediate Microsoft Project
- Preferred Intermediate Healthcare Management Systems (Generic)
- Preferred Intermediate Other Previous experience managing compliance issues via audit/compliance platforms