· Personnel Home · MQ’s · Index · Examination Code: R ·
Nature of Work
Under general direction of the Public Employees Insurance
Agency Director, performs professional advanced level work
providing administrative review, program implementation,
comprehensive program assessment and promotion of health care to
members and providers. In coordination with the management team,
develops, evaluates and implements medical programs that are
consistent with the agency's mission of administering a health
plan that allows appropriate access to quality care, is effective
and efficient in the delivery of health care benefits and that
promotes healthy lifestyles through wellness programs and
preventative care. Program design and implementation must also be
appropriate for CHIP participants. This position is responsible
for special PEIA projects and programs, including development,
implementation and monitoring. Such projects/programs include,
but are not limited to, the SCI grant for expansion of PEIA
coverage to small businesses in West Virginia and Preferred
Provider Network (PPN) development in West Virginia. Performs
related work as required.
Examples of Work
Implements a statewide Preferred Provider Network by July
2004.
Develops a small business insurance product for West Virginia
based businesses.
Develops "specialty networks" for specific diseases and
conditions. An example is obesity services which may require
a network that includes weight loss programs, exercise
programs/facilities, and surgical procedures.
Develops a provider report card for communication to Public
Employees Insurance Agency (PEIA) and Children's Health
Insurance Program (CHIP) providers as a tool for assessing
provider efficiencies and quality of care provided to
patients.
Provides general monitoring and assessment of provider
treatment and billing patterns for PEIA/CHIP patients.
Provides recommendations for changes to the benefit plan that
address issues identified.
Assists in the planning and participates in the annual
statewide provider workshops.
Knowledge, Skills and Abilities
Knowledge and understanding of the practices of insurance
companies and third party administrators.
Knowledge of state and federal regulations, including HIPAA
regulation, as they relate to health insurance.
Knowledge and understanding of provider reimbursement
methodologies including RBRVS, PPS and various other
provider fee schedules.
Knowledge of current health care practices including
appropriate treatment guidelines and utilization procedures.
Ability to communicate effectively, both orally and in
writing.
Ability to maintain effective working relationships with other
employees, employers and government officials.
Minimum Qualifications
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Training:
Bachelor's degree from an accredited college or
university with a major in business, hospital, or health
care administration.
Experience:
Five years of full-time or equivalent part-time
paid experience in the insurance industry with
specialization in provider reimbursement, quality assurance,
marketing, medical policy, and/or utilization management.
Established: 8/21/03
Effective:
10/1/03