Job Code Pay Scale Group Pay Scale Type Bargaining Unit Civil Service or Non-Civil Service Last Executive Board Change Executive Board Change History
44160 11 ST A3 C 771-12 03/26/2021
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JOB CODE: 44160

DEFINITION: This is administrative work directing the oversight and monitoring of the quality, contractual compliance, and operational effectiveness of managed care programs for the Office of Medical Assistance Programs (OMAP) in the Department of Human Services (DHS).

The employee in this job plans and directs the formulation and implementation of plans and strategies to monitor physical health managed care organizations; and evaluates contractor performance in meeting program, policy, quality assurance, health outcomes, and financial requirements. Work involves developing procedures to ensure appropriate guidance and monitoring of the physical health managed care plans; directing Core Teams that conduct ongoing readiness reviews to ensure program quality; monitoring contract compliance to identify areas of noncompliance; approving corrective action plans; and recommending sanctions and penalties. The employee in this job also develops and manages initiatives involving managed care programs, coordinates with managed care programs on implementing corrective action plans, and makes recommendations to the bureau director for further development and improvement of the managed care delivery system. Supervision is exercised over professional, technical, and clerical staff; and work is reviewed by the Director, Bureau of Managed Care Operations, OMAP through conferences, reports, and evaluation of program effectiveness.

EXAMPLES OF WORK: (NOTE: The examples of work are representative of the work, but every position classified to this job may not perform all examples of work listed. Conversely, this is not an all-inclusive list of work examples.)

• Directs activities of multi-discipline Core Teams that monitor all aspects of physical health managed care plans to ensure program quality, contractual compliance, operational effectiveness, and identification of emerging issues.

• Directs the development, evaluation, implementation, and revision of methods and procedures to monitor contract compliance.

• Evaluates program quality, health outcomes, consumer satisfaction, and financial solvency of managed care organizations.

• Coordinates Core Team activities with other OMAP offices, DHS program offices, and commonwealth agencies.

• Directs and participates in the development of Request for Proposals and contracts for managed care.

• Directs staff in establishing, evaluating, and revising readiness review procedures and standards for all managed care providers and answering all provider inquiries about managed care operations.

• Plans, organizes, and directs the review, analysis, and evaluation of managed care service delivery and payment data and projects future program needs.

• Meets with provider associations, subcommittees, and legislative staff to discuss program development and implementation issues, and to facilitate communication among physical health managed care providers.

• Directs staff in the review, analysis, and evaluation of legislation, federal regulations, and state plans to ensure program compliance and continuing program development.

• Oversees the monitoring, evaluating, and provision of technical assistance to managed care providers.

• Performs the full range of supervisory duties.

• The employee in this job may participate in the performance of subordinates’ work consistent with operational or organizational requirements.

• Performs related work as required.


• Knowledge of the laws, regulations, and policies governing medical assistance programs and services.

• Knowledge of the principles and methods of policy and program planning, development, and evaluation.

• Knowledge of the principles and practices of employee supervision.

• Knowledge of the use and functionality of Microsoft Office Suite software.

• Ability to think critically and solve program problems.

• Ability to analyze and interpret written and numerical information.

• Ability to analyze and interpret policies, procedures, and regulations.

• Ability to establish and maintain effective working relationships.

• Ability to communicate effectively orally.

• Ability to communicate effectively in writing.

MINIMUM EXPERIENCE AND TRAINING: (NOTE: Based on the Entry Level Knowledges, Skills, and Abilities)

• Five years of professional experience in medical assistance, health care insurance, or health care services including three years of supervisory experience, and a bachelor's degree;


• An equivalent combination of experience and training which includes three years of professional supervisory experience in medical assistance, health care insurance, or health care services.