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The Delegation Oversight Auditor 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 Delegation Oversight Auditor performs job responsibilities primarily through oversight and monitoring via pre-delegation, annual and focused audits/reviews along with periodic scorecards and related activities, to assess compliance with WellCare's contractual and regulatory requirements and collaborates with business owners and/or delegated vendors to drive remediation. 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.
Review and evaluate the effectiveness of corrective action plans and provide comprehensive follow-up to Senior Management, Market Compliance Oversight Committees, other functional committees and/or the Audit, Finance & Regulatory Compliance Committee of the Board of Directors.
Evaluate the effectiveness of 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 of the utilization of the delegated vendor either directly to WellCare's members or via market, shared services activities through the collection and analysis of data and/or documentation.
Conducts reviews and validations of the performance of the Ineligible Persons Process by delegated entities.
Prepare accurate and timely formal reports (written or electronic) on delegation oversight and monitoring activity findings and recommendations and ensure that work documentation is properly prepared in accordance with WellCare's Compliance Department standards, and that sufficient evidentiary material exists to support delegation oversight and monitoring activity findings.
Provide support for audits and/or reviews (includes internal and external)
Performs other duties as assigned.
Additional Responsibilities:Candidate Education:
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 2 years of experience in Experience in State Medicaid or Federal managed care compliance
Required 1 year of experience in reading, analyzing, and interpreting State and Federal laws, rules and regulations
Required 1 year of experience in participating in a project team with demonstrated ability to drive implementation an influence others
Intermediate Knowledge of community, state and federal laws and resources