DEPARTMENT OBJECTIVE:
The mission of the California Department of Managed Health Care (DMHC) is to protect consumers’ health care rights and ensure a stable health care delivery system. The DMHC accomplishes its mission by ensuring the health care system works for consumers. The Department protects the health care rights of more than 29.7 million Californians by regulating health care service plans, assisting consumers through a consumer Help Center, educating consumers on their rights and responsibilities, and preserving the financial stability of the managed health care system.
PROGRAM OBJECTIVE:
The Help Center assists consumers with health care issues and through its regulatory authority ensures that managed health care patients receive the medical care and services to which they are entitled.
GENERAL DESCRIPTION:
Under the general direction of the Assistant Chief Counsel, Help Center Legal Affairs Branch, the incumbent performs sensitive and complex legal work related to the regulation of health care service plans for the Department of Managed Health Care pursuant to the Knox-Keene Health Care Service Plan Act of 1975, (the Knox-Keene Act, Health, and Safety Code section 1340, et seq.) and other work as required. Duties include evaluating complex consumer complaints, making investigative inquiries, determining compliance with both the Knox-Keene Act and related state and federal provisions, providing expert-level legal advice and counsel to the Help Center’s consumer complaints divisions, and performing other special projects as required.
TYPICAL DUTIES:
Employee must be able to perform the following duties with or without reasonable accommodation.
PERCENTAGE JOB DESCRIPTION
Essential (E)/Marginal (M)
40% (E) Review and evaluate investigative strategies and the handling of complex cases filed with the DMHC’s Help Center against licensed health plans; gather and analyze staff findings for health plan compliance or to initiate legal actions; prepare legal opinions for sensitive issues pertaining to the administration of Help Center programs and the fulfillment of its mission and goals; prepare correspondence to consumers, advocates, and/or private counsel regarding the investigation and resolution of consumer complaints involving complex analytical and factual patterns necessitating the application of multifaceted legal principles, precedents, and/or policies; and prepare referrals for further enforcement investigation, including administrative and/or civil prosecution.
20% (E) Perform a wide variety of the most difficult and complex legal research, including reviewing and interpreting legal precedents and principles contained within federal and state health care laws, regulations, cases, policies, and contracts; make investigative inquiries; interpret laws, rulings and regulations in order to analyze the most complex cases for a determination of compliance with the Knox-Keene Act, DMHC, and DHCS regulations, and applicable federal statutory and regulatory requirements; and provide subject matter expert legal advice and/or legal opinions to management in the Help Center in relation to mental/behavioral health and substance use disorder treatment and other subjects pursuant to the Knox-Keene Act.
20% (E) Develop strategies and tactics to negotiate and respond to difficult matters related to mental/behavioral health and substance use disorder issues involving health care service plan representatives, the Legal Affairs Branch, and the Office of Enforcement. Facilitate and lead meetings between the Legal Affairs Branch and the Office of Enforcement, including providing subject matter expert legal counsel with respect to current issues, policy, and potential emerging concerns related to mental/behavioral health and substance use disorder and other issues.
Monitor, research, and provide expert-level legal analysis with respect to pending legislation affecting Help Center operations.
15% (E) Act as a lead to attorneys in the Legal Affairs Branch, as well as a legal advisor to the Offices of the Director, Enforcement, and Plan Licensing; and provide training and guidance to Help Center clinical and consumer services staff on consumer complaints and emerging issues related to mental/behavioral health and substance use disorder.
5% (M) Conduct special projects involved in the enforcement of State laws and departmental rules and regulations.
SUPERVISION EXERCISED OVER OTHERS:
This position does not supervise others but may act in a lead capacity on special projects.
KNOWLEDGE, ABILITIES AND ANALYTICAL/SUPERVISORY REQUIREMENTS:
The employee should be familiar with DMHC mission, goals, organizational structure, and major work programs. The employee must also have a demonstrated positive attitude and a commitment to conduct business in a professional manner in dealing with the public and department clients and provide quality customer service to all customers, and be able to deal tactfully, professionally, and confidentially with all internal and external customers and contacts.
In addition, the employee must:
Have knowledge of: Legal research methods and performing research; legal principles and their application; scope and character of California statutory law and of the provisions of the California Constitution; federal and state statutes and rules; rules of professional conduct; principles of administrative trial and hearing procedure and rules of evidence; court procedures; legal terms and forms in common use; statutory and case law literature and authorities; professional and ethical rules as they relate to the practice of law; appellate proceedings; rules of evidence and conduct of proceedings in trial and appellate courts of California and the United States and before administrative bodies; and provisions of laws and Government Code sections administered or enforced.
Have ability to research; analyze, appraise, and apply legal principles, facts, and precedents to legal problems; analyze situations accurately and adopt an effective course of action; prepare and present statements of fact, law, and argument clearly and logically in written and oral form; prepare correspondence and memoranda involving the explanation of legal matters; draft opinions, pleadings, rulings, regulations, and legislation; negotiate effectively and conduct crucial litigation; work cooperatively with a variety of individuals, organizations and maintain the confidence and respect of others; independently present difficult and complex cases before Administrative Law Judges; prepare, present, and handle legal cases; direct the work of clerical and professional assistants; edit written documents written by oneself, as well as those produced by others, for accuracy and effectiveness; analyze situations accurately and adopt an effective course of action; reason logically; exercise good judgment; effectively plan and engage in discovery, including depositions and interrogatories, and to compel production or attendance of/at same; independently prepare and present difficult and complex cases before boards, commissions, trial courts, and appellate courts; independently present difficult and complex cases before administrative bodies.
CONSEQUENCE OF ERROR/RESPONSIBILITY FOR DECISIONS:
The employee may have access to very sensitive and confidential information. Careless, accidental, or intentional disclosure of information to unauthorized persons can have far- reaching effects, which may result in civil or criminal action against those involved.
PHYSICAL, MENTAL AND EMOTIONAL REQUIREMENTS:
Employees may be required to sit for long periods of time using a keyboard and video display terminal or traveling in a vehicle to other locations; must be able to organize and prioritize their work under deadline situations and adapt behavior and work methods in response to new information, changing conditions or unexpected obstacles; will be involved with sustained mental activity needed for analysis, reasoning and problem solving; must be able to develop and maintain cooperative working relationships, recognize emotionally charged issues, problems or difficult situations and respond appropriately, tactfully and professionally; and must be able to work independently.
The employee must be able to create/proactively support a work environment that encourages creative thinking and innovation; understand the importance of good customer services and be willing to develop productive partnerships with managers, supervisors, other employees, vendors, and, as required, control agencies and other departments.
WORK ENVIRONMENT:
The DMHC utilizes a hybrid telework model to provide all employees with an avenue to telework while ensuring business and operational needs are met.
Remote-Centered employees are expected to maintain a safe and distraction free work environment at the approved alternate work location. Remote-Centered employees agree to adhere to the state telework policy, the DMHC’s telework policy, and conditions cited in the Telework Agreement (STD 200).
Office-Centered employees are expected to maintain a dedicated workstation at a DMHC official worksite. Office-Centered employees are expected to work in a climate-controlled office or cubicle under artificial lighting.
POSITION REQUIREMENTS:
This position requires the incumbent maintain consistent and regular attendance; communicate effectively (orally and in writing if both appropriate) in dealing with the public, vendors other employees, management and/or supervisors, and, as required, control agencies and other departments; develop and maintain knowledge and skill related to specific tasks, methodologies, materials, tools and equipment; complete assignments in a timely and efficient manner; and, adhere to departmental policies and procedures regarding attendance, leave, and conduct.
Note: Any business travel reimbursements will be done in accordance with the approved applicable Memorandum of Understanding (MOU).
