About the Role: The Bureau of Managed Care within the Division of Insurance is authorized, pursuant to M.G.L. c. 176O, to oversee the managed care practices of insured health plans that either provide or arrange for the delivery of health care services through networks of providers, or that employ utilization review systems to evaluate the medical necessity and appropriateness of requested health care services. The primary purpose of the Bureau of Managed Care is to assist the Commissioner of Insurance in the coordination of managed care reviews, which comprises but is not limited to the following duties:
- Review insurance carriers' biennial applications for managed care accreditation certificates. Review is of carriers' utilization review, quality assurance, credentialing and disclosure practices in relation to national accreditation standards and statutory/regulatory requirements.
- Manage the review of insured health plans' consumer communications, including of evidences of coverage used to define benefits under insured health plans.
- Coordinate with the Commonwealth Health Insurance Connector Authority to ensure that health products offered on the Exchange (also referred to as the marketplace) meet federal benefit requirements and are tested to meet federal requirements.
- Collaborate with staff from the Health Policy Commission's Office of Patient Protection (OPP) to oversee the processing of insured health plans' managed care denials and appeals as overseen by OPP.
- Participate in meetings with other state personnel, including parties representing the Governor's Office; Executive Office of Economic Development agencies, Executive Office of Health and Human Service agencies, Executive Office for Administration and Finance agencies; the Attorney General's Office; the Center for Health Information and Analysis, the Health Policy Commission and the state legislature regarding health care delivery systems.
- Call meetings with external stakeholders to explore health insurance policy issues and develop regulatory guidance where appropriate.
- Provide technical assistance in the development of regulatory guidance applicable to managed care.
- Provide technical assistance in market conduct reviews of individual health insurance company rating, underwriting and sales practices.
- Monitor market trends in health care in collaboration with staff from the Health Care Access Bureau to advise the Commissioner about issues that may impact future coverage options.
- Prepare ad hoc data calls and research reports in response to emerging insurance issues.
- Prepare annual reports as specified by applicable statutes and regulations.
- Prepare and maintain insurance product information for consumers and insurance industry professionals through print materials, the Division's website, and other appropriate communication channels to effectively inform the Division's various audiences.
The Director of the Bureau of Managed Care is a senior management level position that reports to the Deputy Commissioner of the Health Care Access Bureau. The position is responsible for managing the resources and activities of the Bureau's staff and ensuring that the results of the Bureau's efforts are communicated to the appropriate stakeholders.
Duties and Responsibilities: - Monitor changes in market trends for health care and develop recommendations regarding regulatory responses.
- Coordinate resources to ensure that health forms filings are properly reviewed and addressed within statutory and regulatory timeframes.
- Coordinate Bureau staff participation in information sessions conducted at the Division of Insurance to develop guidance regarding appropriate managed care practices.
- Facilitate the development of statutory reports, including the annual report required to evaluate carriers' compliance with uniform coding and mental health parity practices.
- Oversee the accreditation of managed care companies relative to M.G.L. c. 176O.
- Coordinate and communicate with senior management staff to ensure that Bureau staff is aware of developments in other areas of the insurance market that have implications in health insurance mandates and managed care practices.
- Manage Bureau staff by developing goals, delegating tasks, providing guidance and coaching, evaluating performance, hiring, disciplining as required.
- Communicate with the Administration, other state agencies, the Legislature and other external organizations, as required or requested by the Commissioner of Insurance.
- Participate in the meetings and conference calls of the National Association of Insurance Commissioner, as required or requested by the Commissioner of Insurance.
- Other duties, as assigned.
Preferred Knowledge, Skills, and Abilities: - Knowledge of the health care lines of insurance within the responsibility of the Bureau.
- Knowledge of the methods and techniques used in the collection, compilation and analysis of data.
- Ability to prepare reports and make presentations.
- Ability to determine the proper format and procedure for communicating within and outside the agency.
- Ability to maintain accurate records.
- Ability to develop and accept accountability for accurate record keeping of the expenditure of funds for Bureau projects, where applicable.
- Ability to write concisely, to express thoughts clearly and to develop ideas in logical sequence.
- Ability to communicate technical and statistical information to non-technical audiences.
- Ability to establish and maintain harmonious working relationships with others.
- Ability to exercise sound judgment.
- Ability to supervise, including planning and assigning work appropriate to the nature of the job to be accomplished and the capabilities and resources available to the individual performing the work.
- Ability to identify professional development needs of Bureau staff and provide or arrange for such professional development.
- Ability to motivate Bureau staff to work effectively and collaboratively.
- Knowledge of the principles, practices and techniques of supervision.
- Knowledge of the principles of health insurance.
- Significant work experience in health insurance.
- Prior experience with regulation of insurers or businesses.
- Prior experience with coordination of actuarial and technical staff.
- Prior experience with oversight of external contractors/consultants.
All applicants should attach a cover letter and resume to their online submission for this position. Qualifications:MINIMUM ENTRANCE REQUIREMENTS:
Applicants must have at least (A) five (5) years of full-time or, equivalent part-time, professional, administrative, supervisory, or managerial experience in business administration, business management, public administration, public management, clinical administration or clinical management of which (B) at least one (1) year must have been in a project management, supervisory or managerial capacity or (C) any equivalent combination of the required experience and substitutions below.
Substitutions:
I. A certificate in a relevant or related field may be substituted for one (1) year of the required (A) experience.
II. A Bachelor's degree in a related field may be substituted for two (2) years of the required (A) experience.
III. A Graduate degree in a related field may be substituted for three (3) years of the required (A) experience.
IV. A Doctorate degree in a related field may be substituted for four (4) years of the required (A) experience.
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