Aug 24, 2019

Compliance Oversight Specialist - Clinical

  • Professional Diversity Network
  • Tampa, FL, USA
Full-Time Nurse

Job Description

WellCare Health Plans

Position participates in the oversight of WellCare's and/or its delegated subcontractor's corporate ethics and compliance program, and ongoing oversight and analysis of regulatory compliance issues. Conducts focused reviews and audit, oversight, and monitoring activities to assess compliance with clinical aspects of WellCare's contractual and regulatory requirements. Responsible for collaborating with business owners and/or delegated vendors to drive remediation and assist WellCare and delegated subcontractors to maintain integrity through oversight and monitoring and in meeting Government-sponsored health care program requirements.

Reports To: Sr Mgr., Compliance Oversight, Compl-Corporate Compliance

Dept.: Compliance / Corporate Compliance

Location: Henderson Road, Tampa, FL

Essential Functions:

  • Collaborate with and assist those within the Company and the company's delegated subcontractors to maintain integrity through oversight and monitoring and in meeting clinically based requirements of our executed contracts with Government-sponsored health care programs.
  • Assist in the assessment of new and amended Government-sponsored health care program contracts and requirements.
  • Assist Markets (local), Shared Services (corporate), and/or delegated subcontracts in the identification and assessment of clinical (e.g., care management, utilization management, quality improvement plan management and oversight) compliance risks.
  • Evaluate the effectiveness of Market (local), Shared Services (corporate), and/or delegated subcontractor compliance programs and related policies and procedures designed to promote legal and ethical compliance.
  • Prepare accurate and timely formal written reports on oversight and monitoring activity findings and recommendations and ensure workpapers are properly prepared in accordance with WellCare and departmental standards, including sufficient evidentiary material exists to support oversight and monitoring activity findings.
  • Collaborate with other departments and/or delegated subcontractors to direct compliance issues to appropriate channels for research and resolution.
  • Review and evaluate the status and effectiveness of corrective action plans and provide comprehensive follow up to stakeholders, Senior Management, Market Compliance Oversight Committees, and/or the Audit, Finance, and Regulatory Compliance Committee of the Board of Directors.
  • Support external quality reviews and accreditation surveys through preparation of review / survey materials.
  • Participate in special projects as needed, including training.
  • Perform other duties as assigned.
Additional Responsibilities:

Candidate Education:

  • Required An Associate's Degree in Nursing
  • Required A Bachelor's Degree in Nursing
Candidate Experience:
  • Required 3 years of experience in Managed Care/Health Insurance in field
  • Required 1 year of experience in clinical setting or Utilization Management environment
  • Preferred 1 year of experience in project oversight type role with demonstrated ability to drive implementation and influence others
  • Preferred 1 year of experience in reading, analyzing, and interpreting State and Federal laws, rules and regulations
  • Preferred 1 year of experience in State Medicaid or Federal managed care compliance
Candidate Skills:
  • Intermediate Ability to represent the company with external constituents
  • Intermediate Knowledge of community, state and federal laws and resources
  • Intermediate Demonstrated project management skills
  • Intermediate Demonstrated ability to deal with confidential information
  • Intermediate Demonstrated interpersonal/verbal communication skills
  • Intermediate Ability to effectively present information and respond to questions from peers and management
  • Intermediate Demonstrated analytical skills
  • Intermediate Demonstrated written communication skills
  • Intermediate Ability to work independently
  • Ability to multi-task
  • Intermediate Other understanding of operational processes and regulatory requirements
  • Intermediate Other understanding the regulatory framework within which the Company operates
  • Intermediate Other develop partnerships, teamwork and good working relationships
  • Intermediate Other self-motivation, initiative, practical learning skills, and enthusiasm
Licenses and Certifications:
A license in one of the following is required:
  • Required Other active license as a Registered Nurse (RN) or Licensed Practical Nurse (LPN)
Technical Skills:
  • Required Intermediate Microsoft Outlook
  • Required Intermediate Microsoft Word
  • Required Intermediate Microsoft PowerPoint
  • Required Intermediate Microsoft Excel
  • Preferred Intermediate Microsoft Access
  • Preferred Intermediate Healthcare Management Systems (Generic)
  • Preferred Intermediate Other Compliance 360 or similar compliance or audit tracking platform

About us
Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. WellCare is a Fortune 500 company that employs nearly 9,000 associates across the country and was ranked a ''World's Most Admired Company'' in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, sex, age forty (40) and over, disability, veteran status, or national origin.



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