Participates in the oversight of all lines of business within the state, the thorough integration of WellCare's corporate ethics and compliance program, the ongoing oversight and analysis of regulatory compliance based on state contract and the review and approval of all marketing materials prior to approval from state partner.
- Supports regulatory analysis, including the review, summarization and dissemination of key regulatory updates and changes.
- Coordinates the review and investigation of state contract requirements. This function involves interviews, document gathering, investigation summary, recommendations and follow-up. It also involves implementing a system of cataloguing, tracking and trending all investigations.
- Coordinates site visits by Federal and State regulators. This function involves developing work plans, collecting deliverables, reviewing and quality checking deliverables, mock interviews, and site visit facilitation.
- Supports the development of regulatory process flows, with eye toward documentation of departmental processes, report generation, and process improvement.
- Participates in regulatory/compliance-related audits, including the review of departmental documents, interview of departmental staff, summarizing results and implementing recommendations.
- Supports the design, development and implementation of the Regulatory database. Ensure all key departmental processes are captured in the database for tracking and trending purposes.
- Supports the management of the regulatory communications process. Ensure all regulatory communications/updates are received, summarized, catalogued, disseminated and acted upon.
- Coordinates the filing of regulatory forms, reports, etc. Assist other departments in understanding and complying with regulatory requirements. This includes researching regulations, informing departments of regulations, and assisting as needed in developing procedures to comply, as well as drafting responses to queries by regulatory agencies.
- Tracks all issues referred to the Regulatory Affairs Department up to and including resolution.
- Represents the health plan at federal, state, and local government meetings.
- Communicates the importance of compliance and the compliance program to health plan staff, which includes promoting (1) increased awareness of the Corporate Ethics and Compliance Program, (2) understanding of new and existing compliance issues and related policies and procedures, and (3) importance of internal compliance audits.
- Develops and maintain productive relationships with all levels of management as well as regulators and other relevant external parties.
- Provides education and training about laws and regulations that affect operations.
- Works with different functional areas to implement mandates, regulations, and corrective action plans.
- 5 Years of experience in Managed Care/Health Insurance or Masters Degree in Business, Public Health, Health Care Administration, or related field.
- Familiarity with Medicare and Medicaid programs preferred.
- Previous State or Federal managed care compliance experience a plus.
- Experience in effectively presenting information and responding to inquiries from employees, regulatory agencies, and others, as necessary.
- Experience in reading, analyzing, and interpreting State and Federal laws, rules and regulations.
- Knowledge in Microsoft Office including Access, Excel and Word.