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.
Performs multiple cross-functional Internal, State, Federal and Accreditation audits of Utilization Management delivery of health care services. Manages assigned and ad hoc audit schedules, participates in development of audit tools, creates written analyses of audit results. Actively participates in departmental initiatives to ensure audit project timelines and expectations are met.
- Provides data as assigned by Sr. Clinical Compliance Manager and Senior Leadership.
- Presents assigned audit reports to Utilization Management teams, tracks and trends findings, provides recommendations, tracks and trends as indicated.
- Reviews Utilization Management policy and procedures, and Internal processes to ensure compliance with Company, State, Federal and Accreditation regulations.
- Participates in audits and site visits by State, Federal and Accreditation by collecting, reviewing and validating deliverables.
- Provides verbal and written communications related to assigned project, prepares project summary reports and identifies process improvement recommendations.
- Follows WellCare audit guidelines and processes and meets audit and monitoring timelines.
- Other duties as assigned
- Required: A High School or GED with directly related equivalent experience
- Preferred: An Associate's Degree in Nursing, Clinical Social Work/Counseling
- Required: 3+ years of experience in clinical compliance auditing, i.e. CMS, AHCA, NCQA, EQRO or managed care environment
- Preferred: Other Managed Care experience in UM, BH, CM, or DM
- Preferred: Other Familiarity with Medicare and Medicaid programs
- Ability to effectively present information and respond to questions from peers and management
- Demonstrated project management skills
- Demonstrated time management and priority setting skills
- Ability to work within tight timeframes and meet strict deadlines
- Ability to work as part of a team
- Demonstrated interpersonal/verbal communication skills
- Other Ability to read, analyze and interpret state and federal laws, rules and regulations
- Other Ability to assess, analyze, make recommendations and report findings verbally and in a formal written summary
- Other Demonstrated technical expertise in performing quality reviews along with analysis of results.
Licenses and Certifications:
A license in one of the following is required:
- Required: Microsoft Excel
- Preferred: Beginner: Microsoft Access
- Required: Advanced: Microsoft Outlook
- Required: Intermediate: Microsoft Word
- Preferred: Advanced: EMMA
- Required: Advanced: InterQual
- Preferred: Intermediate: Healthcare Management Systems (Generic)