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Dir, HS Delegation and Oversight Raleigh, NC

Company: Wellcare Health Plans
Location: Raleigh
Posted on: July 14, 2019

Job Description:

Director Health Services Delegation and Oversight: Position located in Raleigh, NC:Plans, develops and directs corporate and market delegation functions. Provides leadership necessary to achieve regulatory and accreditation in the oversight and management of delegation entities. Leads and communicates plans about delegation process re-engineering for multiple stakeholders. Oversees end to end process for all delegated vendor reporting and regulatory compliance audits. Partners with legal, network contracting and regulatory in contract language negotiations to ensure compliance of delegated entities. Reports to: VP, Business Performance, PHS-AdministrationDepartment: NC Corporate-PHSPosition location: Raleigh, NC Essential Functions: Manages key project initiatives including the development of detail work plans, setting deadlines, assigning responsibilities, and monitoring/summarizing project progress regarding quality improvement, delegation oversight accreditation, and regulatory compliance. Develops and implements a comprehensive delegation oversight strategy to support accreditation and regulatory compliance. Serves as a central contact for contract delegated issues related to provider and matrix partners. Establishes functional area delegated reporting and reviews system with matrix partners. Provides mentoring, guidance and training to employees and matrix partners regarding delegation structure, process and measures Identifies high impact business opportunities within delegation activities and leads a team end to end for business process improvements. Ensures compliance with delegation audits, implements corrective action plans and facilitates contract compliance with accreditation and regulatory authorities. Participates in state and federal regulatory audits. Develops annual Delegation Performance Improvement Plan and evaluates progress towards identified goals on an annual basis. Evaluates "Best Practices" based on delegation process flow, knowledge of the industry and future trends. Implements actions to drive improvements to delegation oversight process. Provides technical assistance to vendors regarding compliance remediation. Establishes professional relationships with state, stakeholders and vendors to facilitate quality and compliance adherence internally and externally. Develops and implements systems, policies and procedures for the identification, collection, and analysis of delegation performance measurement data. Analyzes, updates, and modifies standard operating procedures and processes to continually improve Delegation Department services/operations. Assists in strategizing and facilitating various committee structures and functions to best address the delegation process and oversees Delegation Oversight Committee. Provides supervision and leadership for Delegation staff and subject matter experts. Serves as liaison with the staff and departments for the purpose of integrative program development in the area of delegation evaluation and reporting with other divisions and departments throughout the enterprise. Communicates new state, federal and third party regulations and requirements to vendors via coordination with matrix partners. Collaborates with Health Services, Operations, and Information Technology departments to ensure full integration of delegated entity reporting for contract and accreditation compliance. Participates in site visit preparation and execution by regulatory and accreditation agencies (state agencies,URAC,NCQA,CMS,AAAHC,EQRO) Monitors and evaluates staff performance. Performs other duties as assigned Education: A Bachelor's Degree in Healthcare, Nursing, Health Administration, Finance, Statistics, hospital/ancillary contracting and network development. Master's Degree in Healthcare preferred. Experience: 10 years of quality improvement experience. 5 years in Managed Healthcare. 5 years in hospital/ancillary contracting and network development. Excellent knowledge of JCAHO, URAC, AAAHC and NCQA standards. 2 years with Medicaid experience. 3-5 years management experienceLicenses/Certifications: Certification in Healthcare Quality by the Healthcare Quality Certification Board, or equivalent (preferred). For FL/IL/MO; RN License preferred. Special Skills (e.g. 2nd language): Excellent understanding of accreditation, federal and state regulations/requirementsExcellent verbal and written communication skillsStrong analytical and problem solving skillsAbility to communicate effectively with people with varying levels of educationAbility to multitask in a fast paced environmentTechnical Skills/Requirements: Proficient in Microsoft Office such as Excel, Word, Visio, PowerPoint and Outlook. 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.

Keywords: Wellcare Health Plans, Raleigh , Dir, HS Delegation and Oversight Raleigh, NC, Other , Raleigh, North Carolina

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