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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 50628000 |
Description Activated On: 9/26/2025 8:07:08 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. Participates in the review process of provider contracts, integrated delivery service arrangements, service area expansions, new applications for HMOs or gatekeeper PPOs, and health insurer network adequacy. May prepare cases at complaint/grievance committee meetings and even 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. Prepares certificate of authority applications for review, submitted by health maintenance organizations (HMOs) for licensure in Pennsylvania. Reviews applications for 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. Recommends and assists in creating technical advice to entities, agencies, and, individuals seeking information on Department of Health and 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. Recommends and drafts policy, legislation, directives, and program proposals as they relate to public health operations, policies and procedures. Coordinates with team to conduct off-site and/or on-site reviews of health plan applicants as needed to verify operational readiness and obtain a license. Collaborates with multiple state agencies and stakeholders to provide technical advice and assistance. Reporting, enforcement, application reviews, contract reviews, appeals, network filing, investigations, and quality assurance reviews as needed on. Reviews service area and expansion requests seeking to operate in new geographic regions of the state. Prepares summarized reports for team to analyze to determine if they are in compliance with state and federal laws. Drafts communication to plan officials regarding deficiencies found during the analysis. Reviews and approves provider contracts meeting standards. Collaborates in intra-agency and inter-agency coordination, and with vendors involved in health program initiatives. Participates as a member of the bureau in consumer grievance appeal committee, receiving and analyzing consumer appeal case files, presenting cases to peers, participates in case review, and, as assigned, drafts decision letters to plans and consumers. In partnership with other bureaus, reviews complaints, grievances, and appeals to identify compliance issues. Participates in on-site inspections of HMOs and other health plans, both independently and in conjunction with external quality reviews conducted by qualified external review organizations, such as the National Committee for Quality Assurance (NCQA). Identifies deficiencies, receives and reviews correction action/quality improvement plans, and monitors compliance with such plans. Coordinates with other bureaus within the Department on corrective action necessary. Participates in special projects relating to managed care as needed or assigned. Develops data collection methods to report and monitor program activities and analyzes data to determine if the service provider meets program requirements. Demonstrates an understanding of and ability to interpret and communicate relevant and available baseline statistics that define the changes and trends in managed care such as 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. 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 is given a great deal of freedom and flexibility in performing 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 product is periodically checked by supervisor. Performance during meetings with regulated entities, during meetings, 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: MINIMUM EXPERIENCE AND TRAINING: (NOTE: Based on the Entry Level Knowledges, Skills, and Abilities) • One year as a Public Health Program Associate 1 (commonwealth title); or • A bachelor's degree and one year of professional experience in the development, analysis, or monitoring of programs, grants, or contracts in health, human services, social or behavioral services, health care services, or health insurance; 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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