WellCare Health Plans, Inc. (NYSE: WCG) provides managed care services exclusively for government-sponsored health care programs, focusing on Medicare and Medicaid. 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 3,800 associates and services nearly 2.4 million members nationwide as of June 30, 2009.

At WellCare, we strive to be the leader in government-sponsored health care programs. Our actions must consistently demonstrate a high level of integrity that earns the trust of those we serve, and all of our associates must be responsible for the commitments we make and the results we deliver. To accomplish this, we must hire and develop the best possible talent, and create a fulfilling environment for our associates where diversity is valued, achievements are recognized and people of all backgrounds and talents are encouraged to grow. The Quality Improvement Analyst (Nurse) coordinates and conducts quality review activities, screens medical records for quality of care issues, coordinates referrals and processes for Physician Peer Review, completes HEDIS^® medical record review and follow-up with members and providers and assists in educational outreach projects to members. 

 
Essential Functions:

• Applies medical knowledge and experience to review referrals and reports and prioritizes according to type of issue
• Requests medical records with appropriate follow up and interaction with medical providers
• Organizes information and documents all processes and interaction thoroughly in Access database and case file
• Applies medical knowledge and experience to review medical records for standard of care compliance
• Applies Medicaid/Medicare and accreditation standards and requirements to all review activity and reporting
• Applies accepted criteria to review process and interprets/utilizes parameters for referral
• Summarizes medical record review thoroughly, concisely and in an organized manner for submission to Medical Director for review
• Identifies potential quality of care issues and refers appropriately to Medical Director all cases reviewed which do not meet established criteria
• Interacts with Medical Director on a one to one basis to assist in research and coordination of Peer Review activities
• Assists Medical Director in composing correspondence to providers
• Prepares reports or studies in an accurate, concise and timely fashion, ensuring data accuracy
• Performs managerial functions in the absence of Manager
• Maintains confidentiality in all communications relating to review and quality improvement activities
• Assures effective communication to the department; updates management on activities and priorities as needed
• Maintains productivity ensuring work is consistently done in relation to volume required for fully proficient performance on the job
• Assists with State and Federal medical record audit activities, including faxing of requests, follow up phone calls, tracking records and other clerical duties as necessary