Participates in the oversight of all lines of business within the state, the 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.
Reports to: VP, M'Caid Prod & Reg Affairs
Department: Legal and Reg Affairs
- Performs comprehensive, complex regulatory analyses, including the review, summarization and dissemination of key regulatory updates and changes.
- Coordinates the review and investigation of state contract requirements. Interviews, gathers documents, creates investigation summaries, makes recommendations and performs follow-up. Implements a system of cataloguing, tracking and trending for all investigations.
- Coordinates site visits by Federal and State regulators. Develops work plans, collects deliverables, reviews and quality checks deliverables, and conducts mock interviews and site visit facilitation.
- Develops regulatory process flows, including the documentation of departmental processes, report generation, and process improvement.
- Provides project leadership for 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. Ensures all key departmental processes are captured in the database for tracking and trending purposes.
- Supports the management of the regulatory communications process. Ensures all regulatory communications/updates are received, summarized, catalogued, disseminated and acted upon.
- Coordinates the filing of regulatory forms, reports, etc. Provides guidance to 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.
- Performs other duties as assigned.
- 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.
- Provides guidance, direction and mentoring to lower level staff members.
- SC Only: Coordinates and facilitates WellCare members’ access to SCDHHS South Carolina Department of Health and Human Services waiver programs.
- Works with governmental agencies to fully understand beneficiary programs and educates staff and members and facilitate connecting members to resources.
- Participates in strategy meetings and make recommendations and provide feedback on WellCare processes relative to the state’s needs.
- Maintains project plans for control of issue resolution.
- Identifies and coordinates with safety net providers to facilitate member referrals, especially for non-core benefits.
- Positively positions WellCare with constituents.
- Serves as an advocate for WellCare at events and activities.
- Required A Bachelor's Degree in
- Preferred A Master's Degree in Business, Public Health, Health Care Administration
- Required 5 years of experience in Managed Care/Health Insurance
- Required Other Previous State or Federal managed care compliance experience
- Required Other Experience in verbal/written communication and presentation skills sufficient to present information and respond to inquiries from employees, regulatory agencies, and others, as necessary
- Required Other Experience in reading, analyzing, and interpreting State and Federal laws, rules and regulations
Licenses and Certifications:
- Intermediate Ability to work within tight timeframes and meet strict deadlines
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Demonstrated written communication skills
- Intermediate Ability to effectively present information and respond to questions from peers and management
- Intermediate Ability to multi-task
- Intermediate Demonstrated organizational skills
- Intermediate Other Ability to exercise good judgment under pressure.
- Intermediate Other Solid knowledge of Medicare and Medicaid programs
- Intermediate Other High level of integrity.
A license in one of the following is required:
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Access
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Outlook