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Director, Health Services Operational Compliance - Tampa Job Details

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Company:  WellCare Health Plans, Inc.
Job Code:  1200056
Categories:  For-Profit Senior Services
Job Role:  Maintenance / Facilities Mgmt / Building & Grounds
Region/Province:  Florida (FL)
City:  FL-Tampa
Job Description:  !*!About WellCare: WellCare Health Plans, Inc. (NYSE: WCG) provides managed care services exclusively for government-sponsored health care programs, focusing on Medicare and Medicaid. Our experience and our exclusive commitment to these programs enable us to serve our members and providers as well as manage our operations effectively and efficiently.

A 2008 Fortune 500 company headquartered in Tampa, Florida, WellCare offers a variety of health plans for families, children and the aged, blind and disabled, as well as prescription drug plans. The company employs approximately 3,500 associates and serves nearly 2.4 million members nationwide as of March 31, 2011. For more information about WellCare, please visit the Company's website at www.wellcare.com.
Assesses Health Services policies, procedures and processes for compliance and current status with Federal requirements, State regulation, State Medicaid requirements, and NCQA requirements and standards in accordance with the States we do business in. . Provides guidance and oversight to the departments within Health Services regarding the requirements of accrediting and regulatory agencies, including but not limited to the Centers for Medicare and Medicaid Services, state Medicaid organizations, and NCQA.  Monitors compliance to policies and procedures through audits, provides and recommends education, and process improvement, congruent to the audit finding and who performs specific tasks related to required communication to members and providers.

 


Essential Functions:


  • Assesses HS operational processes  for compliance with NCQA standards, as well as state/federal contract guidelines and requirements.

  • Coordinates with Regulatory Affairs in each line of business to ensure that corporate policy and addendums are compliant and current.

  • Coordinates with the Training team to ensure that training curriculum supports operational processes as defined in P&Ps.

  • Coordinates schedules for review and revision of P&Ps with HS Corporate Development and Shared Services Teams.

  • Develops audit programs to assess compliance with all Health Services operational processes.

  • Reports audit results and appropriate corrective action plan or process improvement plan to management team and respective market leadership.

  • Leads Health Services operational departmental responses to individual market EQRO/State and CMS audits.

  • Manages the Health Services Compliance team

  • Oversees Compliance staff responsible for research, education and conducts audits.

  • Provides Compliance team performance reports to appropriate leadership representatives.

  • Performs special projects as assigned.

  • Provide consistent audit best practices according to the current literature.

  • Provide internal consultative services to Health Services key stakeholders and market leadership.

  • Serves on committees as requested.

  • Assist in the development of a Clinical strategy integrated with audit and compliance in Health Services.

  • Serves as subject matter expert on clinical policy for all accreditation and audit processes.

  • Collaborate with state and corporate regulatory affairs and compliance departments to assure that clinical policies meet contractual requirements

  • Collaborate to develop value propositions for clinical programs

  • Recognizes and observes all company and departmental policies and procedures.

  • Maintains professional appearance and executive presence by complying with dress code in an appropriate manner

  • Maintain knowledge of competitor programs and industry developments

  • Collaborate with Market Medical Directors and executives


Education:  A Bachelor's degree in Nursing/BSN, or other related field/work experience.  Master's level preferred.  Master's level preferred.                               

 

Experience:  7 years in a regulatory affairs or compliance environment.  At least 5 years in healthcare delivery.  Managed care experience preferred. 3-5 years management/supervisory experience.

 

Licenses/Certifications:  Active unencumbered Clinical license.        


 

Special Skills (e.g. 2nd language): 

·         Demonstrated success implementing tools/techniques, quality programs Education, training or professional experience in medical or clinical skills. 

·         Strong knowledge of managed care principles, research design & analysis, medical terminology and cost/benefit analysis

·         Previous experience in a leadership and medical policy/process is preferred           

·         Strong knowledge of Medicare, Medicaid & State requirements

·         Ability to multi-task and balance projects

·         Solid project management skills

·         Demonstrated ability to lead others

·         Ability to influence management at all levels

 

Technical Skills/Requirements: 


  • Proficient in use of internet for research

  • Intermediate skills in Microsoft Office such as Excel, Access, PowerPoint, Word and Outlook. 


Post Date:  02/20/2012

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