Participates in required audits and site visits, as well as coordinates all compliance related activities throughout various functional areas in support of operational goals. Thorough integration of WellCare's corporate ethics and compliance programs and ongoing oversight, analysis, and communication of regulatory compliance to all of Operations.
Department: Ops, Claims
Report To: Director, Claims Audit
Location: Tampa, FL 33634/ Houston ,TX 77081
- Research legal/regulatory documentation and perform analysis, including the review and summarization of regulatory requirements, updates and changes.
- Coordinates the policy and procedure process including the review and approval of policy modifications, as well as any other supporting documentation, including the design, review, cataloguing, dissemination and annual updating.
- Develops regulatory process flows with focus on documentation of departmental processes, report generation, and process improvement.
- Participates in audits and/or site visits by Federal State Regulatory accrediting bodies and outsourced vendors, including the development of work plans, collecting deliverables, reviewing and quality checking deliverables, participate in team meetings and issue mitigation.
- Provides project leadership for operations compliance-related initiatives including completion of corrective action plans and providing the appropriate audit response.
- Collaborates with other departments to direct compliance issues to appropriate channels for investigation and resolution. Consults with management, in-house counsel, and/or VPs as needed to resolve difficult compliance issues.
- Works cohesively with different functional areas across multiple levels to communicate and implement mandates and new regulations and provides guidance to associates for any operations compliance-related issues.
- May participate in special projects as needed including auditing, training, and HIPAA compliance.
- Supports the management of the regulatory communications process in Operations ensuring all regulatory communications/updates are received, summarized, catalogued, disseminated and acted upon.
- Provides project leadership for compliance-related audits, including the review of departmental documents, summarizing results and implementing recommendations.
Education: BA/BS required. Master's Degree preferred. Equivalent experience may be considered in lieu of degree.
Experience: 7 years of experience in Managed Care/Health. Familiarity with Medicare and Medicaid programs preferred. Previous State or Federal managed care compliance experience. 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.
Technical Skills/Requirements: Strong knowledge of Microsoft Office(including Outlook, Word, Excel, Powerpoint, and Access). Knowledge of flow charting tool to create and maintain process flows. Project management experience and skills in using a project planning tool a plus.