Director, Bureau of Managed Care

Commonwealth of Massachusetts•Boston, MA

About The Position

The Division of Insurance (DOI), an agency within the Office of Consumer Affairs and Business Regulation, administers the Commonwealth’s insurance consumer protection laws. Its work includes monitoring the solvency of licensees, responding to consumer inquiries and complaints, enforcing insurance laws and regulations, and providing accurate and unbiased insurance information. The Division is committed to a welcoming, inclusive, equitable, and mutually respectful workplace. The Bureau of Managed Care oversees managed care practices of insured health plans under M.G.L. c. 176O. It assists the Commissioner of Insurance with coordinated reviews, including reviews of carriers’ managed care accreditation applications, utilization review, quality assurance, credentialing, disclosure practices, consumer communications, and health plan benefit materials. The Bureau also coordinates with other state agencies on health products, denials and appeals, health care delivery systems, regulatory guidance, market conduct reviews, market trends, data requests, reports, and consumer and industry information. The Director is a senior management-level position responsible for managing Bureau resources and staff activities and communicating the results of the Bureau’s work to appropriate stakeholders. The Director reports to the Deputy Commissioner of the Health Care Access Bureau.

Requirements

At least five 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.
At least one year of the required experience must be in a project management, supervisory, or managerial capacity, or an equivalent combination of experience and allowed substitutions.
Ability to prepare reports and make presentations.
Ability to determine appropriate formats and procedures for communication within and outside the agency.
Ability to maintain accurate records and be accountable for accurate records of Bureau project expenditures where applicable.
Ability to write concisely, express thoughts clearly, and develop ideas in logical sequence.
Ability to communicate technical and statistical information to non-technical audiences.
Ability to establish and maintain harmonious working relationships.
Ability to exercise sound judgment.
Ability to supervise, including planning and assigning work in light of the work to be accomplished and available capabilities and resources.
Ability to identify Bureau staff professional development needs and provide or arrange appropriate development.
Ability to motivate Bureau staff to work effectively and collaboratively.
Knowledge of the principles, practices, and techniques of supervision.
A relevant or related certificate may substitute for one year of the required experience; a related bachelor’s degree may substitute for two years; a related graduate degree may substitute for three years; and a related doctorate may substitute for four years.

Nice To Haves

Knowledge of the health care insurance lines within the Bureau’s responsibility.
Knowledge of methods and techniques for collecting, compiling, and analyzing data.
Significant work experience in health insurance.
Prior experience regulating insurers or businesses.
Prior experience coordinating actuarial and technical staff.
Prior experience overseeing external contractors or consultants.
Knowledge of the principles of health insurance.

Responsibilities

Monitor changes in health care market trends and develop recommendations regarding regulatory responses.
Coordinate resources to ensure health form filings are reviewed and addressed within statutory and regulatory timeframes.
Coordinate Bureau staff participation in Division information sessions to develop guidance on appropriate managed care practices.
Facilitate statutory reports, including the annual report evaluating carriers’ compliance with uniform coding and mental health parity practices.
Oversee managed care company accreditation under M.G.L. c. 176O.
Coordinate and communicate with senior management to ensure Bureau staff are aware of developments in other insurance market areas that affect health insurance mandates and managed care practices.
Manage Bureau staff by developing goals, delegating tasks, providing guidance and coaching, evaluating performance, hiring, and disciplining as required.
Communicate with the Administration, other state agencies, the Legislature, and external organizations as required or requested by the Commissioner of Insurance.
Participate in National Association of Insurance Commissioners meetings and conference calls as required or requested by the Commissioner of Insurance.
Perform other duties as assigned.
Review carriers’ biennial applications for managed care accreditation certificates, including utilization review, quality assurance, credentialing, and disclosure practices.
Manage reviews of insured health plans’ consumer communications, including evidence of coverage documents.
Coordinate with the Commonwealth Health Insurance Connector Authority to ensure Exchange health products meet and are tested against federal benefit requirements.
Collaborate with the Health Policy Commission’s Office of Patient Protection on oversight of managed care denials and appeals processing.
Participate in meetings with state personnel and other public-sector stakeholders regarding health care delivery systems.
Convene external stakeholders to discuss health insurance policy issues and develop regulatory guidance where appropriate.
Provide technical assistance in developing managed care regulatory guidance and conducting market conduct reviews of individual health insurance company rating, underwriting, and sales practices.
Monitor health care market trends with the Health Care Access Bureau and advise the Commissioner about issues that may affect future coverage options.
Prepare ad hoc data calls and research reports in response to emerging insurance issues.
Prepare annual reports required 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 communication channels.