JOB TITLE: DIRECTOR, BUREAU OF MANAGED CARE, PID

JOB CODE: 34580

DEFINITION: This is professional managerial work in the field of managed care and the regulation of health care plans in the Pennsylvania Insurance Department.

The employee in this job directs the Bureau of Managed Care and is responsible for planning, developing, reviewing, implementing, and coordinating oversight of managed care plans on a statewide basis. Work includes establishing program goals and objectives, and policies and procedures for review of network adequacy, quality assurance programs, and other data collection required of managed care organizations and certified review entities; formulating and publicly advocating for substantive program policy relating to network adequacy and quality; reviewing and commenting on state and federal legislation pertinent to these statewide programs; preparing reports on program operations and problems, as well as data reported by managed care organizations; evaluating accessibility, quality of care, and program effectiveness; and meeting with local, state, and federal public health officials, community organizations, and the general public. Work is assigned in the form of broad goals and objectives, and the employee exercises considerable independence in determining program goals, objectives, and priorities. Work is reviewed by the Deputy Insurance Commissioner for Product Regulation and Administration for conformance with federal and state policies and 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 a staff engaged in planning, developing, reviewing, implementing, and coordinating accountability measures for managed care plans across the commonwealth.

• Establishes program goals, objectives, policies, and procedures.

• Reviews and comments on state and federal legislation pertinent to statewide managed care delivery systems and the regulation of health care plans and assists in the preparation of proposed laws and regulations affecting managed care.

• Prepares reports on program operations and problems to assist staff in developing priorities, policies, and methods to increase and improve program effectiveness.

• Evaluates program effectiveness through reports, conferences, and attainment of goals and objectives.

• Meets with local, state, and federal public health officials to develop new or expanded existing health insurance programs related to managed care and health care coverage.

• Serves as the principal advisor to the Deputy Insurance Commissioner on health care systems, accessibility, quality, and program development matters.

• Directs the development of regulations for health maintenance organizations and preferred provider organizations as they pertain to accountability and protection provisions, such as accessibility and quality of care.

• Integrates all managed care health developmental activities with other department programs.

• Interprets rules, regulations, policies, standards, and objectives of the organization or program for subordinates.

• Directs the licensing and consumer grievance functions for managed care entities.

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

• Performs the full range of supervisory duties.

• Performs related work as required.

ENTRY LEVEL KNOWLEDGES, SKILLS, AND ABILITIES:

• Knowledge of the theory, principles, practices, and current developments in the field of managed care.

• Knowledge of the federal and state laws governing managed care health delivery systems and health care plans.

• Knowledge of the programs of health maintenance organizations, preferred provider organizations, and managed care systems.

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

• Ability to prepare reports on program operations and problems.

• Ability to review and comment on state and federal legislation affecting health delivery systems and health care plan development.

• Ability to read and interpret rules and regulations.

• Ability to communicate effectively orally.

• Ability to communicate effectively in writing.

• Ability to establish and maintain effective working relationships.

FULL PERFORMANCE KNOWLEDGES, SKILLS, AND ABILITIES: (NOTE: These are expected of an employee performing the work of this job at the full performance level. These are not used for merit system evaluation or examination purposes and are not position-specific performance standards.)

• Ability to plan, develop, review, implement, and coordinate managed care delivery systems and developmental programs.

• Ability to establish program goals, objectives, policies, and procedures.

• Ability to formulate and publicly advocate substantive program policy for managed care.

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

• Four years of professional health insurance experience, two years of which must have been administrative or supervisory experience, and a master’s degree;

or

• Five years of professional health insurance experience, two years of which must have been administrative or supervisory experience, and a bachelor's degree;

or

• An equivalent combination of experience and training, which includes two years of professional administrative or supervisory health insurance experience