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Assists the Regional Director, Market Compliance Officer with the implementation of policies, procedures, and practices designed to assure compliance with the requirements set forth in federal and state Plan contracts, laws, regulations, and health care program requirements. Partners with the contact for the Regional Director, Market Compliance Officer assisting with identifying, tracking, mitigating, and reporting operational compliance risks in the Market, and with the development and facilitation of compliance and ethics activities in the Market. Partners with the Regional Director, Market Compliance Officer as the local contact for the Corporate Compliance Department's functional units.
Assist the Regional Director, Market Compliance Officer 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.
Provide subject matter expertise on the conditions and terms of WellCare's federal and state contracts, to the market.
Develop meeting agendas and lead the Market Compliance Oversight Committee, at least quarterly, and facilitates other Compliance Committees, as contractually required. Ensure meeting minutes are collected and archived.
Assist the Regional Director, Market Compliance Officer on completion of Market Compliance Assessment – Quarterly Performance Report Work plan and compile Quarterly Performance Report for submission to Market leadership and Regional Director, Market Compliance Officer.
Facilitates WellCare's Internal Audit on Market-based assessments, and partnering with Regional Director, Market Compliance Officer.
Serve as the primary point of contact for the escalation path within the Market for compliance related and ethical issues and involve the appropriate resources and support from Corporate Compliance as needed.
Develop, implement, conduct, and track on-site compliance trainings and provide updates to Regional Director, Market Compliance Officer.
Provide subject matter expertise for HIPAA, assess compliance with HIPAA requirements, perform periodic HIPAA audits of office location(s) and guide remediation plans, partnering with Director, Market Compliance Officer, as needed.
Serve as primary 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, partnering with the Regional Director, Market Compliance Officer.
Communicate the status of key compliance activities, new and emerging compliance issues and compliance metrics by participating in Market leadership meetings, as needed, and consulting with Market and Corporate leaders.
Participate in regularly scheduled one on one meetings with Regional Director, Market Compliance Officer.
Serve as a Market compliance resource and assist the Regional Director, Market Compliance Officer 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 Officer, as appropriate.
Collaborate with Market Leadership to identify risks and monitor processes to ensure compliance with state and federal health care program requirements, partnering with Regional Director, Market Compliance Officer, as needed.
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, partnering with Regional Director, Market Compliance Officer, as needed.
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, partnering with Regional Director, Market Compliance Officer, as needed. .
In collaboration with Regional Director, Market Compliance Officer and 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 Regional Director, Market Compliance Officer and Market leaders, Vice President, Compliance Oversight, Market Regulatory Affairs, Internal Audit, and fellow Directors, Market Compliance Officer, as needed.
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.
Conduct 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, partnering with Regional Director, Market Compliance Officer.
Monitor results of internal and external audits, escalated issues, notices of non-compliance, warning letters, non-audit CAPs, fines, penalties, liquidated damages or sanctions, partnering with Regional Director, Market Compliance Officer, as needed.
Provide oversight for monitoring and tracking of Market Compliance Program metrics, structure, process and oversight, partnering with Director, Market Compliance Officer, as needed.
Other projects and duties as assigned by the Regional Director, Market Compliance Officer.
Additional Responsibilities:Candidate Education:
Required A Bachelor's Degree in a related field
Required or equivalent work experience 3 years of relevant work experience
Preferred A Master's Degree in Business Administration, Public Health, or Healthcare Administration
Required 3 years of experience in business setting
Preferred Other Experience in Corporate compliance, regulatory affairs or state government preferred
Preferred Other Managed care experience preferred
Intermediate Ability to drive multiple projects
Intermediate Ability to work within tight timeframes and meet strict deadlines
Intermediate Demonstrated written communication skills
Intermediate Ability to effectively present information and respond to questions from peers and management
Intermediate Ability to work in a matrixed environment
Intermediate Demonstrated interpersonal/verbal communication skills
Intermediate Knowledge of community, state and federal laws and resources
Intermediate Other Must exercise keen judgment in difficult situations, balancing the competing interests of corporate and regional offices in a matrix management system
Intermediate Other Demonstrated experience developing and delivering training programs and making presentations to staff and providers