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.
Sr Mgr., Compliance Oversight, Compl-Corporate Compliance
/ Corporate Compliance
Henderson Road, Tampa, FL
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.
Required An Associate's Degree in Nursing
Required A Bachelor's Degree in Nursing
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
Intermediate Ability to represent the company with external constituents
Intermediate Knowledge of community, state and federal laws and resources
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)
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 www.wellcare.com. 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.