Assists the Regional Director, Market Compliance with the implementation of policies, procedures, and practices designed to ensure compliance with the requirements set forth in federal and state Plan contracts, laws, regulations, and health care program requirements. Serves as the contact for the Regional Director, Market Compliance on compliance and ethics activities in the Market. Functions as the local contact for the Corporate Compliance Department's functional units and serve as a Market resource for identifying, tracking, mitigating and reporting on operational compliance risks.
- Assist the Regional Director, Market Compliance with the implementation and oversight of the policies, procedures and practices designed to ensure compliance with the requirements set forth in federal and state Plan contracts, laws, regulations, and health care program requirements.
- Serve as the Market's subject matter expert on the conditions and terms of WellCare's federal and state contracts.
- Establish and lead the Market Compliance Committee. Ensure meeting minutes are collected and archived.
- Complete Market Compliance Assessment – Quarterly Performance Report Work plan and compile Quarterly Performance Report for submission to Market leader and Regional Director, Market Compliance.
- Partner with WellCare's Internal Audit Department on Market-based assessments
- Guide the escalation path within the market for compliance related and ethical issues and involve the appropriate resources and support from Corporate Compliance as needed.
- Conduct and track on-site compliance trainings and provide updates to the field organization.
- Serve as Market subject matter expert for HIPAA, assess compliance with HIPAA requirements, perform periodic HIPAA audits of office location(s) and guide remediation plans.
- Serve as Market Local Record Coordinator for the Records Information Management department. Perform training and oversight as needed.
- Serve as the local compliance and oversight contact for Compliance applications (LIONS, C360).
- Collaborate with Regulatory Affairs to remain current on state regulatory register, comply with reporting requirements and serve as an integrated compliance voice during the planning and execution phases of Market programs and projects.
- Communicate the status of key compliance activities, new and emerging compliance issues and compliance metrics by regularly participating in Market leadership meetings and consulting with leaders as needed.
- Participate in regularly scheduled one on one meetings with Market leader.
- Serve as the Market compliance resource and assist the Regional Director, Market Compliance with monitoring the day-to-day compliance activities at the applicable Market. Create and submit periodic (at least semi-annual) written reports regarding compliance matters directly to the Regional Director, Market Compliance, as appropriate.
- Collaborate with Market Leadership to identify risks and monitor processes to ensure compliance with state and federal health care program requirements.
- Consult with business owners of contract requirements and electronically validate their contract assessments in the Corporate Compliance system. Perform validation reviews and risk assessments to evaluate compliance contract requirements and business processes.
- Monitor contract uploads in Corporate Compliance system to ensure all requirements documented including amendments, handbooks, policy transmittals and statutes
- Collaborate with Market Regulatory Affairs, Delegated Oversight and Legal departments to monitor vendor compliance. Review delegation oversight tools, subcontracts and provider agreements to ensure they meet regulatory requirements.
- In collaboration with Compliance Oversight, prepare, monitor and drive remediation of identified risks.
- Build relationships with key business owners to collect and review operational reports to monitor compliance and communicate risks. Communicate risk information and performance scores to Market leaders, Vice President, Compliance Oversight, Market Regulatory Affairs, Internal Audit, and fellow Directors, Market Compliance.
- Provide oversight of the internal and external audit process including: risk assessment, external audit management, preparation and facilitation. Perform targeted reviews of operational and contractual compliance.
- Partner with Compliance Special Investigation teams, including conducting investigations relative to agent Sales & Marketing and enrollment FWA cases and conducting interviews with potential beneficiaries, members, agents, providers, associates and/or downstream entities as required for investigatory purposes.
- Monitor results of internal and external audits, escalated issues, notices of non-compliance, warning letters, non-audit CAPs, fines, penalties, liquidated damages or sanctions.
- Provide oversight for monitoring and tracking of Market Compliance Program metrics, structure, process and oversight.
- Other projects and duties as assigned.
This position is contingent upon the bid award in the state of New Mexico to WellCare Health Plans, Inc.1Education:
- A Bachelor's Degree in a related field OR 5 years equivalent work experience required.
- A Master's Degree in Business Administration, Public Health, or Healthcare Administration preferred.
- 5 years of relevant work experience.
- 5 years of experience in business setting required.
- Experience in Corporate compliance, regulatory affairs or state government preferred.
- Managed care experience preferred.
- Ability to drive multiple projects.
- Ability to work within tight timeframes and meet strict deadlines.
- Demonstrated written communication skills.
- Ability to effectively present information and respond to questions from peers and management.
- Ability to work in a matrixed environment.
- Demonstrated interpersonal/verbal communication skills.
- Knowledge of community, state and federal laws and resources.
- Ability to exercise keen judgment in difficult situations, balancing the competing interests of corporate and regional offices in a matrix management system.
- Demonstrated experience developing and delivering training programs and making presentations to staff and providers.
Intermediate proficiency in Microsoft Outlook, Word, Excel and PowerPoint.
Knowledge of and/or ability to utilize a budgetary software applications