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*Clinical Delegation Oversight Auditor - Long Beach, CA-1305060

IBM Type Full time Posted 4/23/2014
Salary - n/a - Starts - n/a -
CA - California (All) - Long Beach Referral - n/a -    
About WellCare: WellCare Health Plans, Inc. provides managed care services targeted to government-sponsored health care programs, focusing on Medicaid and Medicare. Headquartered in Tampa, Fla., WellCare offers a variety of health plans for families, children, and the aged, blind and disabled, as well as prescription drug plans. The company serves approximately 3.3 million members nationwide as of January 1, 2014. The company employs more than 5,100 nationwide. For more information about WellCare, please visit the company's website at www.wellcare.com. A Fortune 500 company traded on the New York Stock Exchange (symbol: WCG).

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.
 
Description
 
Supports the delegation of processes across multiple product lines by performing pre-delegation assessments, ongoing delegation oversight and auditing of delegated entities so as to ensure their policies and procedures, documentation, systems, staffing and ability to provide reports are operational and are in compliance with regulatory/statutory and as applicable accreditation guidelines.  Acts as the subject matter expert in interpreting requirements and ensuring the overall areas for delegation are functional and in compliance with the Plan's regulatory contracts.  Assesses clinical care and activities related to quality, utilization management, and case management, interfaces with a diverse range of clinical and administrative professionals, resolves complex issues, and performs data analytic and reporting activities.
 *LI-CW1
Essential Functions:
  • Conducts pre-delegation and annual audits for new and existing delegated entities for the following clinical areas: Utilization Management, Quality and Appeals.
  • Ensures the provider continues to perform the delegated activities in accordance with the agreement and regulatory requirements.
  • Develops, revises and maintains all delegation audit tools and written agreements as necessary to comply with state and Federal regulatory requirements.
  • Prepares all audit reports including correspondence and corrective action plans to ensure that provider satisfies all requirements within allotted timeframes.
  • Maintains all documentation to support evidence of compliance with all delegation requirements.
  • Attends monthly Delegated Oversight Committee meetings.
  • Conducts mock audits of department functions using State and accreditation audit tools and develops corrective action plans to address any identified issues.
  • Provides support to the department supervisors in identifying training needs.
  • Prepares all State and Federal audit materials and attends audit prep sessions relative to delegation of credentialing.
  • Analyzes, updates, and modifies procedures and processes to continually improve QI operations
  • Collects and summarizes performance data, identifies opportunities for improvement, and presents findings to Quality Improvement Committees
  • Serves as knowledge expert for clinical and quality areas.
  • Monitors and analyzes outcomes to ensure goals, objectives, outcomes, accreditation and regulatory requirements are met
  • Participates in site visit preparation and execution by regulatory and accreditation agencies (State agencies, CMS, AAAHC, URAC, NCQA,EQRO)
  • Supports the implementation of the quality reporting infrastructure.
  • Ensures that documentation produced and/or processes followed comply with state regulations and/or accrediting body requirements
  • Ensures that assigned contract/regulatory report content is accurate and that submission adheres to deadline
Qualifications
 
Education:  Bachelor's degree in health service delivery, business administration, related field required or equivalent work experience.                                                       
 
Experience:  2+ year's clinical experience. 2+ year's  auditing experience (Appeals, Credentialing, Customer Service, Claims, UM etc.).  3+ year's experience in Managed Care/Health Insurance.  Familiarity with Medicare and Medicaid programs preferred.  Previous State or Federal managed care compliance experience, accreditation and service of quality improvement a plus.
 
Licenses/Certifications:  Current RN or LCSW unrestricted license required.      
 
Special Skills (e.g. 2nd language):   
Excellent communication skills
Ability to communicate effectively with people with varying levels of education
Ability to multitask in a fast paced environment
 
Technical Skills/Requirements:  Proficient in Microsoft Word, Excel, PowerPoint, Outlook and database management.

Primary Location

 CA-Long Beach

Is a relocation package available?
 No