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Job Description - Director of Pharmacy Benefit Manager Oversight V)

Job Description

Director of Pharmacy Benefit Manager Oversight - ( V )

Description

About the Organization:

The Division of Insurance ("DOI"), an Agency within the Office of Consumer Affairs and Business Regulation, administers the Commonwealths insurance consumer protection laws through its regulation of the insurance industry. The primary mission of the Division is to monitor the solvency of its licensees in order to promote a healthy, responsive and willing marketplace for consumers who purchase insurance products. The Division also investigates and responds to consumer inquiries and complaints, enforces state insurance laws and regulations, and provides the public with accurate and unbiased insurance information. An important aspect of the Divisions work is ensuring that the individuals and business entities conducting the business of insurance in Massachusetts do so in a legal and timely manner.

The Division of Insurance is committed to creating and sustaining a work culture that is welcoming, inclusive, and mutually respectful to all its employees regardless of race, color, age, creed, religion, national origin, ethnicity, sex, gender identity or expression, sexual orientation, genetic information, veteran or disability status. We strive to reflect diversity in all facets and levels of our agency. The Division of Insurance values inclusiveness and diversity within their employee and management teams. Within our community we strive to create and maintain working and learning environments that are inclusive, equitable, and welcoming.

The Division of Insurance is committed to ensuring a diverse and inclusive workplace where all employees feel respected, valued, and empowered to maximize their skills and talents to serve our citizens.

About the Role:

The Director of Pharmacy Benefit Manager Oversight operating within the Health Care Access Bureau is authorized, pursuant to M.G.L. c. 176Y, to oversee the practices of licensed Pharmacy Benefit Managers, including their operations with insured health plans that either provide or arrange for the delivery of health care services through networks of providers, or that employ utilization review systems to evaluate the medical necessity and appropriateness of requested health care services. The primary purpose of the Director of Pharmacy Benefit Manager Oversight is to assist the Commissioner of Insurance and Deputy Commissioner of the Health Care Access Bureau, in the coordination of pharmacy benefit reviews, which comprises but is not limited to the following duties:

• Oversee the review of Pharmacy Benefit Managers applications for licensure. Review is of carriers operations, including utilization review, quality assurance, contracts with pharmacies and prescription drug manufacturers, and of their disclosure practices in relation to regulatory standards and statutory requirements.
• Manage the review of pharmacy benefit manager consumer communications, including explanations of benefits given to consumers, employers or health care providers.
• Collaborate with staff from the Health Policy Commission to oversee the collection of information related to Pharmacy Benefit Managers and the processing of insured health plans pharmacy benefit denials and appeals as overseen by OPP.
• Participate in meetings with other state personnel, including parties representing the Governors Office; Executive Office of Economic Development agencies, Executive Office of Health and Human Service agencies, and Executive Office for Administration and Finance agencies; the Attorney Generals Office; the Center for Health Information and Analysis, the Health Policy Commission and the state legislature regarding health care delivery systems.
• Call meetings with external stakeholders to explore pharmacy benefit policy issues and develop regulatory guidance where appropriate.
• Provide technical assistance in the development of regulatory guidance applicable to pharmacy benefits.
• Provide technical assistance in market conduct reviews of individual Pharmacy Benefit Manager practices.
• Monitor market trends in pharmaceutical benefits in collaboration with staff from the Health Care Access Bureau and Bureau of Managed Care to advise the Commissioner about issues that may impact future coverage options.
• Prepare ad hoc data calls and research reports in response to emerging pharmaceutical benefit issues. Prepare periodic and annual reports, including those specified by applicable statutes and regulations.
• Prepare and maintain pharmacy benefit information for consumers and the insurance industry in print, on the Divisions website and through other vehicles deemed appropriate to inform the Divisions various audiences.

The Director of Pharmacy Benefit Manager Oversight is a senior management level position that reports to the Deputy Commissioner of the Health Care Access Bureau. The position is responsible for managing the resources and activities of the Bureaus staff and ensuring that the results of the Bureaus efforts are communicated to the appropriate stakeholders.

Duties and Responsibilities:

• Monitor changes in market trends for pharmacy benefits and develop recommendations regarding regulatory responses.
• Coordinate resources to ensure that pharmacy benefit manager filings are properly reviewed and addressed within statutory and regulatory timeframes.
• Coordinate Pharmacy Benefit Manager Oversight staff participation in information sessions conducted at the Division of Insurance to develop guidance regarding appropriate pharmaceutical benefit practices.
• Facilitate the development of reports, including the reports that may be required to evaluate carriers compliance with coding and claims practices.
• Oversee the licensure of Pharmacy Benefit Managers relative to M.G.L. c. 176Y.
• Coordinate and communicate with senior management staff to ensure that staff are aware of developments in other areas of the insurance market that have implications in health insurance mandates and managed care practices.
• Manage staff working in Pharmacy Benefit Manager Oversight by developing goals, delegating tasks, providing guidance and coaching, evaluating performance, etc.
• Communicate with the Administration, other state agencies, the Legislature and other external organizations, as required or requested by the Commissioner of Insurance.
• Participate in the meetings and conference calls of the National Association of Insurance Commissioner, as required or requested by the Commissioner of Insurance.

Preferred Knowledge, Skills and Abilities:

• Knowledge of the Pharmacy Benefit Manager and health care lines of insurance within the responsibility of the Bureau.
• Knowledge of the methods and techniques used in the collection, compilation and analysis of data.
• Ability to prepare reports and make presentations.
• Ability to determine the proper format and procedure for communicating within and outside the agency.
• Ability to maintain accurate records.
• Ability to develop and accept accountability for accurate record keeping of the expenditure of funds for Bureau projects, where applicable.
• Ability to write concisely to express thoughts clearly and to develop ideas in logical sequence.
• Ability to communicate technical and statistical information to non-technical audiences.
• Ability to establish and maintain harmonious working relationships with others.
• Ability to exercise sound judgment.
• Ability to supervise, including planning and assigning work appropriate to the nature of the job to be accomplished and the capabilities and resources available to the individual performing the work.
• Ability to identify professional development needs of Bureau staff and provide or arrange for such professional development.
• Ability to motivate Bureau staff to work effectively and collaboratively.
• Knowledge of the principles, practices and techniques of supervision.
• Knowledge of the principles of health insurance.
• Prior experience with regulation of insurers or businesses.
• Prior experience with coordination of actuarial and technical staff.
• Prior experience with oversight of external contractors/consultants.

All applicants should attach a cover letter and resume to their online submission for this position.

Qualifications

MINIMUM ENTRANCE REQUIREMENTS:

Applicants must have at least (A) five (5) 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 of which (B) at least one (1) year must have been in a project management, supervisory or managerial capacity or (C) any equivalent combination of the required experience and substitutions below.

Substitutions:

I. A certificate in a relevant or related field may be substituted for one (1) year of the required (A) experience.

II. A Bachelor's degree in a related field may be substituted for two (2) years of the required (A) experience.

III. A Graduate degree in a related field may be substituted for three (3) years of the required (A) experience.

IV. A Doctorate degree in a related field may be substituted for four (4) years of the required (A) experience.

When you embark on a career with the Commonwealth, you are offered an outstanding suite of employee benefits that add to the overall value of your compensation package. We take pride in providing a work experience that supports you, your loved ones, and your future.

An Equal Opportunity / Affirmative Action Employer. Females, minorities, veterans, and persons with disabilities are strongly encouraged to apply.

The Commonwealth is an Equal Opportunity Employer and does not discriminate on the basis of race, religion, color, sex, gender identity or expression, sexual orientation, age, disability, national origin, veteran status, or any other basis covered by appropriate law. Research suggests that qualified women, Black, Indigenous, and Persons of Color (BIPOC)may self-select out of opportunities if they don't meet 100% of the job requirements. We encourage individuals who believe they have the skills necessary to thrive to apply for this role.

Official Title : Program Manager VI

If you have Diversity, Affirmative Action or Equal Employment Opportunity questions or need a Reasonable Accommodation, please contact Diversity Officer / ADA Coordinator : Michael Powers -

Bargaining Unit : M99-Managers (EXE)

Confidential : No

Potentially Eligible for a Hybrid Work Schedule : Yes