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.
REPORTS TO: Sr. Manager, Compliance Oversight
- 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.
- 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 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
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
- Intermediate demonstrated interpersonal/verbal communication skills
- Intermediate ability to effectively present information and respond to questions from peers and management
- Intermediate ability to work in a fast paced environment with changing priorities
- Intermediate demonstrated written communication skills
- Intermediate demonstrated time management and priority setting skills
- Intermediate good analytical skills and an understanding of operational processes and regulatory requirements
- Intermediate understands the regulatory framework within which the Company operates
- Intermediate ability to develop partnerships, teamwork and good working relationships
- Intermediate demonstrates self-motivation, initiative, practical learning skills, enthusiasm and an ability to complete multiple tasks in a timely and accurate manner
- Intermediate 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
- Required intermediate Microsoft PowerPoint
- Required intermediate Microsoft Visio
- Required intermediate Microsoft Project
- Required intermediate Microsoft Word
- Preferred beginner Microsoft Outlook
- Preferred intermediate Healthcare Management Systems (Generic)