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Serves as a department SME for a wide range of tasks and special functions to include vendor support, training, quality reviews, new business implementations, root cause analysis, reporting analytics, process improvement, etc. Also serves in a leadership capacity to perform a wide range of complex operational activities based on business needs and ensures operations are functioning in accordance with all regulatory requirements.
Serves as liaison between department and business partners, both internal and external.
Identifies, evaluates, recommends and implements data-driven process improvement initiatives.
Manages and leads complex assignments and special functions such as vendor oversight, contracting, inventory monitoring, reporting, new business implementations, quality reviews, root cause analysis, training, operational processes, etc.
Maintains/ Creates resources applicable to assigned area, such as timely updates to training, announcements, step actions, reference call tools, FAQs etc.
Leads activities in cross functional environment and collaborates with leadership to implement new processes.
Leads, manages, monitors, performs UAT and complete key improvement projects in an accurate and timely manner.
Partners with WellCare vendors supporting operations. Supports and assists all LOB's with specific focus on Health Services, Pharmacy, Medicaid, Exchanges, Medicare and PDP, etc.
Assists leadership team with resource management, including distribution of work, recruiting, staff training and performance input.
Investigates problems of a moderately complex nature and provide findings, impact, remediation and preventative actions in a clear and concise manner.
May participate in internal audit activities.
Conducts /supports assessment audits of the operational areas for multiple product lines to determine the operations' degree of readiness for compliance to the appropriate state or federal regulatory requirements. Collaborates with operations regarding level of understanding of the respective requirements.
Verifies scope of the audit assessment meets the state and federal requirements. Presents scope of assessments and plans to operations management.
Documents assessment results including areas of non-conformance and prepares audit reports including correspondence and corrective action plans to ensure all requirements are satisfied within the designated timeframes. Works with Delegation Oversight team as needed. Presents results to operations management.
May develop, revise, and maintain audit tools as deemed appropriate.
Conduct annual review of department policies and procedures for multiple product lines to meet our state or federal regulatory requirements.
Analyzes data and reports to identify trends, operational issues, financial impact of implemented initiatives, etc. May need to run existing SQL queries to generate data into Excel to conduct research and analysis.
Performs all other related duties as assigned.
Additional Responsibilities:Candidate Education:
Required A High School or GED
Preferred A Bachelor's Degree in a related field
Required 5 years of experience in a related field based on assigned area
Preferred Other Previous health care experience
Preferred Other Previous supervisory experience
Advanced Demonstrated analytical skills
Intermediate Ability to implement process improvements
Intermediate Demonstrated written communication skills
Intermediate Demonstrated interpersonal/verbal communication skills
Advanced Ability to communicate and make recommendations to upper management
Advanced Other Strong understanding of managed care and its place in the health care industry
Advanced Other Understanding of interdependencies on other business units
Licenses and Certifications: A license in one of the following is required: Technical Skills: