Job Description
- 23.07 - $36.91 Hourly
- 47,989 - $76,782 Annually
This position is a Pay Band 65
Posting Details
The OSI enforces New Mexico law on insurance matters, including consumer protections, review of insurance forms and rates for accuracy and fairness, and helps New Mexicans address insurance concerns. The Managed Health Care Bureau assists consumers with their grievances filed under commercial managed health care plans in the State of New Mexico and enforces the provisions of the Patient Protection Act, NMSA 1978, §59A-57 and related healthcare regulations. The Bureau investigates, assists and resolves inquiries and complaints. The Bureau also reviews external grievance appeals, proposes rule amendments, and takes appropriate enforcement actions where merited. In addition, the Bureau conducts regular consumer outreach across the State to inform consumers and health care providers of their rights and responsibilities under the Affordable Care Act. We also handle health care provider complaints filed against health care insurers subject to the insurance laws and regulations of this State.
Why does the job exist?
The purpose of this position is to assist consumers and providers with their grievances filed against health insurance carriers, offering managed health care plans in the State of New Mexico and enforce the provisions of the Patient Protection Act as well as the Provider Grievances, Grievance Procedures and Provider Payment and Provider Credentialing Requirement Rules. Position investigates, assists and resolves inquiries and complaints regarding, but not limited to, payment of claims and denials of medically necessary benefits. Technical review and investigation are performed in accordance with state statutes and regulations applicable to commercial managed health care plans. Additionally, this position performs outreach with the State of New Mexico, educating consumers regarding their rights to appeal health insurance carrier's adverse determinations.
How does it get done?
Position assists consumers in understanding their rights regarding coverage, medical necessity and claim denials. Investigates and responds to consumer inquiries and complaints within the scope of the Grievance Rule, 13.10.17 NMAC. Serve as a liaison between the insurance carrier and the complainant to resolve complaints.
Incumbent of this position will perform technical review and investigation of member coverage under health plans subject to the jurisdiction of the Office of Superintendent of Insurance. The Compliance Officer-A determines the type of coverage a member has, if it falls within in our agency's jurisdiction and ensure that complaint is understandable, complete, accurate, and within
mandated time frames. Duties also include tracking time frames, guiding consumers in handling complaints throughout the internal and external review processes. Ensure that investigation of external grievance cases is thorough and supporting documentation is compiled and organized in a manner that facilitates OSI legal staff to develop a defensible case. Prepare and assist with external review hearings.
Assist in providing outreach services to include education and appeal rights to consumers in the State of New Mexico regarding their patient rights. Conduct presentations to groups on the functions of OSI-MHCB.
Perform other miscellaneous duties, as assigned.
Who are the customers?
Primarily New Mexico consumers with commercial managed health care insurance. Internal customers include staff at the Office of Superintendent of Insurance.
Ideal Candidate
- Superb technical writing and customer service skills.
- 2 years of experience in consumer relations, medical billing, regulation, compliance.
- Experience in healthcare law and/or insurance.
- Bilingual.
Minimum Qualification
Bachelor's degree in Business Administration and two (2) years of experience in investigations, regulation, policy, statutory, and/or contract compliance. Any combination of education from an accredited college or university in a related field and/or direct experience in this occupation totaling six (6) years may substitute for the required education and experience.
Substitution Table
These combinations of education and experience qualify you for the position:
Education Experience Education Experience 1 High School Diploma or Equivalent AND 6 years of experience OR High School Diploma or Equivalent AND 6 years of experience 2 Associate's degree in the field(s) specified in the minimum qualification AND 4 years of experience Associate's degree or higher in any field AND 6 years of experience 3 Bachelor's degree in the field(s) specified in the minimum qualification AND 2 years of experience 4 Master's degree or higher in the field(s) specified in the minimum qualification AND 0 years of experience
- Education and years of experience must be related to the purpose of the position.
- If Minimum Qualification requires a specific number of "semester hours" in a field (e.g. 6 semester hours in Accounting), applicants MUST have those semester hours in order to meet the minimum qualifications. No substitutions apply for semester hours.
Employment Requirements
Must possess a valid New Mexico Driver's license, a current defensive driving course certification from the State of New Mexico or must pass Defensive Driving Course Certificate within six months of the date of hire as a condition of continued employment.
Working Conditions
Work is usually performed in an office setting, with continuous exposure to Visual/Video Display terminal (VDT), and extensive personal computer and telephone usage with extended periods of sitting. Some standing, bending and reaching may be required. Must be able to lift 25 lbs.
Supplemental Information
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Agency Contact Information: Gurrattanpal "Mickey" Singh. Email
For information on Statutory Requirements for this position, click the Classification Description link on the job advertisement.
Bargaining Unit Position
This position is covered by a collective bargaining agreement and all terms/conditions of that agreement apply and must be adhered to. State of New Mexico
Job Tags
Hourly pay, Contract work,