Clinical Delegation Oversight Auditor, Sr at WellCare Health Plans

Posted in Health Care 28 days ago.

This job brought to you by Professional Diversity Network, Inc

Type: Full Time
Location: Cypress, California





Job Description:

Reports to: VP Field Health Service
Location: Cypress, CA
Job Type: Exempt
Participates in the clinical oversight of WellCare's and/or WellCare's delegated vendor's corporate ethics and compliance program, and the ongoing oversight and analysis of regional regulatory compliance issues. Performs job responsibilities primarily through conducting clinically focused reviews and other monitoring and oversight activities to assess compliance with WellCare's contractual and regulatory requirements.
Essential Functions:
Review of clinical functions and collaborates with other departments and/or delegated vendors to direct clinical compliance issues to appropriate channels for investigation and resolution. Consults with management, in-house counsel, delegated vendors, and/or the VP of Regulatory Compliance as needed to resolve difficult compliance issues.
Regular interaction with all departments, management, associates, delegated vendors, and/or regulatory agencies regarding compliance issues.
Review and evaluate the effectiveness of corrective action plans that address audit report findings and provide comprehensive follow-up to Senior Management, market Compliance oversight Committees, and/or the Regulatory Compliance Committee of the Board of Directors.
Track the status and completion of all corrective action plans and ensure the implementation of all recommendations derived from each focused review, oversight and/or monitoring activity.
Evaluate the effectiveness of various compliance programs and related policies and procedures designed to promote legal and ethical compliance.
Identify and assess compliance risks within the Company and/or with the Company's delegated vendors.
Serves as a compliance advisor to various business units or delegated vendor.
Participates in the ongoing development of educational and training tools for the Compliance Program that seeks to ensure all associates are knowledgeable of and comply with pertinent Federal and State laws and regulations.
Assists with the development, initiation, maintenance and revision of Compliance Program policies, procedures and practices for the general operation of the Program.
Assists Corporate Audit & Oversight management with the development and execution of key departmental initiatives.
May participate in special projects as needed including auditing, training, and HIPAA compliance.
Communicates the importance of compliance and the compliance program to health plan staff and/or delegated vendors, which includes promoting (1) increased awareness of the Corporate Ethics and Compliance Program, (2) understanding of new and existing compliance issues and related policies and procedures, and (3) importance of oversight and monitoring activities.
This position serves to educate, encourage and assist those within the Company and with the Company's delegated vendors to maintain integrity through oversight and monitoring and in meeting the requirements of the Annual Work Plan within State Medicaid Programs, OIG and CMS work plan requirements.
Provides education and training about laws and regulations that affect operations internally and/or through delegated vendor relationships.
Provides guidance, direction and mentoring to lower level staff members.
Performs other duties as may be assigned. Additional Responsibilities: Candidate Education:
Required An Associate's Degree in Nursing, Pharmacy, or Other Clinical related discipline and a Registered Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), or Licensed Clinical Social Worker (LCSW) designation
Preferred A Bachelor's Degree in Nursing, Pharmacy, or Other Clinical related discipline
Preferred A High School or GED Business, Public Health, Health Care Administration Candidate Experience:
Required 5 years of experience in Managed Care/Health Insurance
Required 2 years of experience in a project oversight type role with demonstrated ability to drive implementation and influence others
Required 3 years of experience in Experience in State Medicaid or Federal managed care compliance.
Preferred Other Previous experience managing compliance issues via audit/compliance platforms. Candidate Skills:
Intermediate Knowledge of community, state and federal laws and resources Licenses and Certifications:
A license in one of the following is required:
Required Licensed Registered Nurse (RN)
Required Licensed Practical Nurse (LPN)
Required Licensed Vocational Nurse (LVN)
Required Licensed Specialist Clinical Social Worker (LSCSW) Technical Skills:
Required Intermediate Microsoft Project
Required Intermediate Microsoft Access
Preferred Intermediate Healthcare Management Systems (Generic)
Required Intermediate Microsoft Excel
Required Intermediate Microsoft Word
Required Intermediate Microsoft PowerPoint
Required Intermediate Microsoft Outlook Languages:
About us
Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 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, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.