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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 50569530 |
Description Activated On: 3/2/2026 8:15:02 AM |
Position Purpose: Describe the primary purpose of this position and how it contributes to the organization’s objectives. Example: Provides clerical and office support within the Division to ensure its operations are conducted efficiently and effectively. Organizes documents for the Bureau of Health Coverage Access, Administration, and Appeals (HCA3) needed to review provider contracts, integrated delivery service arrangements, service area expansions, new applications for HMOs or gatekeeper PPOs, and health insurer network adequacy. May assist in preparing cases at complaint/grievance committee meetings and participate as a member of the complaint/grievance committee. Duties are performed with supervision. |
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Description of Duties: Describe in detail the duties and responsibilities assigned to this position. Descriptions should include the major end result of the task. Example: Types correspondence, reports, and other various documents from handwritten drafts for review and signature of the supervisor. Participate in and receive on the job training to learn the multifaceted way the state agencies collaborate in regard to insurer and managed care reporting, complaints, grievances, enforcement, application reviews, contract reviews, appeals, network filing, investigations, and quality assurance reviews as needed. Reviews Utilization Review Entity and Independent Review Organization applications for completeness in compliance with applicable laws, regulations, statements of policy and guidelines. Responds to questions by collaborating with the team, researching, and reviewing existing documentation, regulations, and laws. Communicates application deficiencies verbally and in writing to applicants. Participates in drafting policy, legislation, regulations, directives, and program proposals as they relate to Bureau operations, policies, and procedures. Monitors incoming inquiries to determine if there are trends to recommend areas where technical advice or guidance may be needed for entities, agencies, and, individuals seeking information on Insurance Department rules and regulations regarding licensure of managed care plans, compliance with Department standards, and mental health parity analyses related to network adequacy, credentialing, etc. Organizes inbound requests for service area and expansion requests seeking to operate in new geographic regions of the state. Assists team members in various activities needed to support health care plan compliance with state and federal laws. Becomes familiar with communication activities between the bureau and the plan officials regarding deficiencies found during the analysis. Learns about the process of contract and application reviews and review standards. Observes the advisory group meetings identifying compliance issues in consumer appeals. Become familiar with how to build consumer appeal case files, present cases to peers, participate in case review, and draft decision letters to plans and consumers. Participates in the Medicaid, CHIP, and ABD external grievance review processes. Assigns independent review organizations (IRO) requests. Creates IRO assignment letters. Processes IRO decision notices. Reviews IRO decision notices for compliance with requirements. Responds to phone inquiries. Becomes familiar with data collection, baseline statistics, trends, and report processes regarding enrollment data, complaints and grievances, county level penetration rates and other similar measures. Prepare reports, studies and recommendations to assist program managers in their need for additional policy, legislation, regulations, and directives. Assists in preparing certificate of authority applications for review, submitted by health maintenance organizations (HMOs) for licensure in Pennsylvania. Adheres to all Department policies/guidelines and legislation regarding data release and confidentiality. Performs other duties as assigned. |
Decision Making: Describe the types of decisions made by the incumbent of this position and the types of decisions referred to others. Identify the problems or issues that can be resolved at the level of this position, versus those that must be referred to the supervisor. Example: In response to a customer inquiry, this work involves researching the status of an activity and preparing a formal response for the supervisor’s signature. Employee performs assigned tasks and duties within the confines of managed care law, regulation, statement of policy, and Bureau guidelines. Because of the constant evolution of managed care, employees are expected to identify unusual or new proposals, suggest possible responses to supervisor, and to discuss potential precedent setting decisions with supervisor. Work products are periodically checked by supervisor. Performance during meetings with regulated entities when providing technical advice and assistance is monitored by supervisor. |
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Requirements Profile: Identify any specific experience or requirements, such as a licensure, registration, or certification, which may be necessary to perform the functions of the position. Position-specific requirements should be consistent with a Special Requirement or other criteria identified in the classification specification covering this position. Example: Experience using Java; Professional Engineer License Experience: A bachelor’s degree in health, social or behavioral sciences, statistics, or a related field; or an equivalent combination of experience and training. Licenses, registrations, or certifications: 1. N/A 2. N/A 3. N/A 4. N/A 5. N/A 6. N/A |
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Essential Functions: Provide a list of essential functions for this position. Example: Transports boxes weighing up to 60 pounds.
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