HEALTH ECONOMIC SPECIALIST

Class Definition The Health Economic Specialist is responsible for carrying out various regulatory functions as assigned by OHIC’s Director of Regulatory Compliance, or their designee, including, but not limited to: Health Insurance Carrier Benefit Determination and Insurance Carrier Benefit Coverage Document Review: Primary staff person responsible for the day-to-day review of health insurance carrier benefit determination and network plan document filings for certification under the supervision of OHIC’s Director of Regulatory Compliance, or their designee : Review and process of benefit determination and provider network document filings submitted to OHIC for approval and certification.
Keep benefit determination and provider network documents submitted by carriers and related agencies updated in the System of Electronic Rate and Form Filing (SERFF) Communicate with OHIC staff to resolve benefit determination and provider network documents as well as certification filing issues Submit to the OHIC Director of Regulatory Compliance, or their designee, necessary updates to benefit determination filing instructions and certification documents in SERFF.
Assist in Market Conduct Review as determined by OHIC Executive Legal Counsel and/or OHIC Director of Regulatory Compliance.
Complaint Management: Primary staff person responsible for consumer benefit determination and network plan inquiries and complaints under OHIC jurisdiction, under the supervision of OHIC’s Director of Regulatory Compliance, or their designee : Process and triage all consumer and provider communications received to include telephone, mail, fax, and in-person contacts.
Respond to consumer and provider inquiries regarding benefit determination and insurer network questions interfacing with other Rhode Island consumer resource agencies.
Resolution of these consumer and provider complaints under OHIC jurisdiction and the transfer of complaints to other state or federal agencies as appropriate.
Real time documentation of all consumer contacts in the State Based System (SBS) to the point of resolution or agency transfer.
Data Management: Working with the OHIC Principal Policy Associates and Director of Regulatory Compliance along with the Consulting Actuaries to ensure data and document collection accuracy for benefit determination reviews and certifications.
Other data management tasks involving the State Based System (SBS) which houses benefit determination and provider network inquiries and complaints combined with reporting from OHIC’s Consumer Assistance vendor.
Monitoring of SERFF benefit determination and certification related filings to include submitting required reports and information to federal health insurance agencies as required.
Committee Meetings and Interagency Interface: Under the direction of OHIC Director of Regulatory Compliance, attend meetings to support rate and form review as well as consumer protections.
Communication with other state agencies and organizations in an effort to conduct form review and to process consumer inquiries and complaints.
Other tasks as assigned by OHIC’s Director of Regulatory Compliance, or their designee, and/or the Health Insurance Commissioner.
Illustrative Examples of Work Performed Demonstrated proficiency and hands-on experience in health care insurance, federal and state benefit determination processes, federal and state network adequacy requirements, health care delivery systems, payment methodology, health insurance consumer advocacy/protection, health benefit designs, and health insurance regulation.
Substantial experience implementing federal market reforms, independently drafting requests for information, and facilitating health-related working groups.
Experience reviewing certificates of coverage, health insurance carriers' policies and procedures, and subscriber agreement documents.
In-depth understanding of state and federal mandated benefits, mental health parity, coupled with the ability and demonstrated track record to communicate effectively in both oral and written forms.
Experience managing vendors/consultants to meet internal deliverables.
Proven ability to work independently, prioritize tasks, and meet established deadlines, along with relevant capabilities and skills.
Required Qualifications for Appointment Such as may be gained through possession of a bachelor’s degree with a specialization in health care administration, communications, or business administration.
Such as may have been gained through a minimum of five (5) years of experience in servicing in a responsible position in the health insurance or related industry.
OR any combination of education and experience that shall be substantially equivalent to the above education and experience.
Supplemental Information A cover letter and resume are required.