Serves as Lead in various Projects for the Medical Affairs Team.

Manage and maintain end to end creation and submission of UM Materials and Correspondence as lead SME for PHS Correspondence Project teamFunction as UM material project lead for all new and acquired WellCare business and initiatives including but not limited to; Medicare Expansion Projects (AEP),, Acquisitions & Mergers and QAIsEngage with Regulatory and Compliance partners to ensure adherence to material requirements and State/Federal approval process as requiredDevelop material crosswalks for presentation during meetings with new business partnersProvide communication updates regarding all new and revised Member and Provider materials to UM Business Partners, Delegation Oversight and Vendor Relations to ensure consistent access to most recent versioningInteract with Business Partners and all departments to assure fulfillment of commitments and requirements Provide/prepare UM Materials for IPA Vendors for approval and co-branding.Review and provide Business Owner approval for materials provided by IPA Vendors ensuring that their letters meet all Regulatory requirementsProvide SME support to the Quality Auditors regarding UM material issues and submission of CareCentral tickets as needed Maintain documentation and updates to department job aids. Maintain UM Material status tracking and Correspondence SharePoint siteConducted manual Audit File Prep for all Lines of Businesses in preparation for Mock Audits and the actual upcoming AuditsTrained Team members from the Clinical Business Monitoring Team on the electronic File Prep process used for prepping Audit filesResponsible for maintaining the UM Correspondence site where all Active and Archived UM Materials for the EMMA Platform are housedResponsible for maintaining the Business Standards and Development Correspondence site so that it is current and up to date for the Quality Team and Delegation Oversight Team to use for audit purposes.Create Job Aids and Process Flows for our department

Monitors and audits both Medicare and Medicaid products to ensure both internal and external performance and regulatory requirements are in compliance. Collaborates with Care Management leadership on developing audit tools and audit project plans. Ensures audit and monitoring timelines are met. Provides support to the communications process which includes provider and member adverse notifications, QIO routing, and Physician reconsideration routingProvides support for the adverse determination process which includes ensuring notification meets regulatory/contractual requirements for content and timeliness. Produces adverse determination information in support of an audit, monitoring or appeal requestAssists management in developing project plans to ensure ongoing monitoring and oversight of utilization management functions.Assists management with the collection of data and performs audits of utilization management functional areas, including but not limited to: Prior Authorization, Inpatient Concurrent review, and SNF Concurrent Review.Provides support for all regulatory audits, including CMS and State Medicaid. Supports other compliance and/or regulatory projects as needed. Communicates the importance of compliance and the compliance program to health plan staff. Promotes an increased awareness of the corporate ethics and compliance program. Conveys new and existing compliance issues and related policies and procedures.Develops and maintains productive relationships with all levels of area management as well as regulators and other relevant external parties.Performs special projects as assigned.