Key Staff Requirements. The MCO’s Key Staff must also meet the following requirements, as applicable: 1. The Chief Executive Officer/Chief Operating Officer (CEO/COO) or West Virginia MHT Vice President/Senior Vice President shall serve in a full time (forty [40] hours per week) position available during BMS business hours to fulfill the responsibilities of the position and to oversee the entire operation of the MCO. The CEO/COO or West Virginia MHT Vice President/Senior Vice President shall devote sufficient time to the MCO’s operations to ensure adherence to program requirements and timely responses to BMS. The CEO/COO or West Virginia MHT Vice President/Senior Vice President shall be authorized and empowered to make contractual, operational, and financial decisions for the contract, related to business, claims payment, provider relations/contracting, and all other functions of the MCO. The CEO/COO or West Virginia MHT Vice President/Senior Vice President must be directly employed by the MCO. The CEO/COO or West Virginia MHT Vice President/Senior Vice President must attend in person, upon BMS request, meetings, and hearings of legislative committees, interested governmental bodies, agencies, and officers. The CEO/COO or West Virginia MHT Vice President/Senior Vice President must establish and maintain positive client relationships, make contractual, operational, and financial decisions on behalf of the MCO, and oversee and provider overarching contract oversight for the MCO. The CEO/COO or West Virginia MHT Vice President/Senior Vice President must have at least ten (10) years’ experience in Medicaid managed care oversight and operations, ten (10) years’ experience in healthcare administration and operations, a bachelor’s degree or higher and be based in West Virginia. 2. The Contract Liaison/MHT Administrator is responsible for overall delivery of the project, serving as a liaison with BMS during all phases of the contract. The Administrator must attend in person, upon BMS request, meeting and hearings of legislative committees and interested governmental bodies, agencies, and officers. The Administrator must maintain a positive client relationship, provide timely and informed responses to operational and administrative inquires that arise, meet with BMS staff or such other persons as designated by BMS on a regular basis to provide oral and written status reports and other information as required. The Administrator must respond to issues involving information systems and reporting, appeals, quality improvement, member services, service management, pharmacy management, medical management, and care coordination. The Administrator must ensure that each member has an ongoing source of care appropriate to his or her needs and a person or entity formally designated as primarily responsible for coordinating the services accessed by the member, per 42 CFR §438.208(b)(1). The Administrator must have at least five (5) years’ experience in Medicaid managed care contract oversight and five (5) years’ experience in healthcare, experience working with low-income populations, and cultural sensitivity, a bachelor’s degree or higher and be based in West Virginia 3. The Chief Financial Officer (CFO) is responsible for oversight of all financial activities of the project. The CFO must oversee the MCO’s provider payment arrangements, including Alternative Payment Models (APMs), sign data certification forms, including, at a minimum, all encounter data and financial data and reporting for payments to contracted providers, and certified payment information to be utilized for rate-setting purposes or any payment-related data required by the Department. The CFO must have at least five (5) years’ experience serving as a financial lead for a managed care entity or other health insurance provider and a bachelor’s degree or higher. 4. The Compliance Officer is responsible for all compliance-related activities, including developing and implementing policies, procedures, and practices designed to ensure compliance with the requirements of this contract, and State and federal regulations. The Compliance Officer shall report directly to an Executive Compliance Officer at the corporate level of the organization and indirectly to the CEO/COO. The Compliance Officer will serve as the primary contact person for all BMS MHT compliance requests and concerns. The Compliance Officer must have at least five (5) years’ experience serving as a compliance officer or lead in the healthcare industry for a Medicaid managed care or other healthcare entity, a bachelor’s degree or higher and be based in West Virginia. 5. The Medical Director, who is a physician with a current, unburdened license through the West Virginia State Medical Board, shall have at least three (3) years of training in a medical specialty. The Medical Director shall devote full time (a minimum of thirty-two [32] hours per week) to the MCO’s operations to ensure timely medical decisions, including after-hours consultation as needed. The Medical Director shall be actively involved in all major clinical and quality management components of the MCO. The Medical Director must have at least five (5) years’ experience in serving as Medical Director for a Medicaid program and five (5) years’ experience working in pediatric care, an active West Virginia Medical License and be based in West Virginia. 6. Medical Management Director is responsible for oversight of utilization management activities of the project, including oversight and management of processing referrals and pre-authorization requirements, as well as familiarity with appeals procedures. The Director must respond to requests from the BMS’s Medical Director or Contract Administrator within three (3) business days. The Director must have at least five (5) years’ experience working as a utilization management manager or specialist for a Medicaid program, be a registered nurse (RN) or Licensed Clinical Social Worker (LCSW) in West Virginia and be based in West Virginia. 7. The Care Management (CM) Director shall be responsible for overseeing the day-to-day operational activities of the Care Management Program in accordance with state guidelines. The CM Director is responsible for ensuring the functioning of care management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring, and evaluating). The CM Director shall have experience in the activities of care management as specified in 42 CFR §438.208. The Director must have at least five (5) years’ experience working as a case manager or care coordinator for a Medicaid program, be a West Virginia licensed registered nurse (RN) or a West Virginia licensed independent social worker with a demonstrated ability to communicate with members who have complex medical needs and may have communication barriers. The Director must be based in West Virginia. 8. The Behavioral Health (BH) Medical Director must employ or contract with an independent, active, and unrestricted West Virginia medical license in a related behavioral health specialty. The BH Medical Director must have at least five (5) years’ experience in serving as BH Lead or expert for a Medicaid program and five (5) years’ experience working in BH clinical care, including substance use. The BH Medical Director shall demonstrate knowledge of West Virginia’s overall BH system, which includes mental health, alcohol and drug addiction, and developmental disabilities
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Key Staff Requirements. The MCO’s Key Staff must also meet the following requirements, as applicable:
1. The Chief Executive Officer/Chief Operating Officer (CEO/COO) or West Virginia MHT Vice President/Senior Vice President shall serve in a full time (forty [40] hours per week) position available during BMS business hours to fulfill the responsibilities of the position and to oversee the entire operation of the MCO. The CEO/COO or West Virginia MHT Vice President/Senior Vice President shall devote sufficient time to the MCO’s operations to ensure adherence to program requirements and timely responses to BMS. The CEO/COO or West Virginia MHT Vice President/Senior Vice President shall be authorized and empowered to make contractual, operational, and financial decisions for the contract, related to business, claims payment, provider relations/contracting, and all other functions of the MCO. The CEO/COO or West Virginia MHT Vice President/Senior Vice President must be directly employed by the MCO. The CEO/COO or West Virginia MHT Vice President/Senior Vice President must attend in person, upon BMS request, meetings, and hearings of legislative committees, interested governmental bodies, agencies, and officers. The CEO/COO or West Virginia MHT Vice President/Senior Vice President must establish and maintain positive client relationships, make contractual, operational, and financial decisions on behalf of the MCO, and oversee and provider overarching contract oversight for the MCO. The CEO/COO or West Virginia MHT Vice President/Senior Vice President must have at least ten (10) years’ experience in Medicaid managed care oversight and operations, ten (10) years’ experience in healthcare administration and operations, a bachelor’s degree or higher and be based in West Virginia.
2. The Contract Liaison/MHT Administrator is responsible for overall delivery of the project, serving as a liaison with BMS during all phases of the contract. The Administrator must attend in person, upon BMS request, meeting and hearings of legislative committees and interested governmental bodies, agencies, and officers. The Administrator must maintain a positive client relationship, provide timely and informed responses to operational and administrative inquires that arise, meet with BMS staff or such other persons as designated by BMS on a regular basis to provide oral and written status reports and other information as required. The Administrator must respond to issues involving information systems and reporting, appeals, quality improvement, member services, service management, pharmacy management, medical management, and care coordination. The Administrator must ensure that each member has an ongoing source of care appropriate to his or her needs and a person or entity formally designated as primarily responsible for coordinating the services accessed by the member, per 42 CFR §438.208(b)(1). The Administrator must have at least five (5) years’ experience in Medicaid managed care contract oversight and five (5) years’ experience in healthcare, experience working with low-income populations, and cultural sensitivity, a bachelor’s degree or higher and be based in West Virginia.
3. The Chief Financial Officer (CFO) is responsible for oversight of all financial activities of the project. The CFO must oversee the MCO’s provider payment arrangements, including Alternative Payment Models (APMs), sign data certification forms, including, at a minimum, all encounter data and financial data and reporting for payments to contracted providers, and certified payment information to be utilized for rate-setting purposes or any payment-related data required by the Department. The CFO must have at least five (5) years’ experience serving as a financial lead for a managed care entity or other health insurance provider and a bachelor’s degree or higher.
4. The Compliance Officer is responsible for all compliance-related activities, including developing and implementing policies, procedures, and practices designed to ensure compliance with the requirements of this contract, and State and federal regulations. The Compliance Officer shall report directly to an Executive Compliance Officer at the corporate level of the organization and indirectly to the CEO/COO. The Compliance Officer will serve as the primary contact person for all BMS MHT compliance requests and concerns. The Compliance Officer must have at least five (5) years’ experience serving as a compliance officer or lead in the healthcare industry for a Medicaid managed care or other healthcare entity, a bachelor’s degree or higher and be based in West Virginia.
5. The Medical Director, who is a physician with a current, unburdened license through the West Virginia State Medical Board, shall have at least three (3) years of training in a medical specialty. The Medical Director shall devote full time (a minimum of thirty-two [32] hours per week) to the MCO’s operations to ensure timely medical decisions, including after-hours consultation as needed. The Medical Director shall be actively involved in all major clinical and quality management components of the MCO. The Medical Director must have at least five (5) years’ experience in serving as Medical Director for a Medicaid program and five (5) years’ experience working in pediatric care, an active West Virginia Medical License and be based in West Virginia.
6. Medical Management Director is responsible for oversight of utilization management activities of the project, including oversight and management of processing referrals and pre-authorization requirements, as well as familiarity with appeals procedures. The Director must respond to requests from the BMS’s Medical Director or Contract Administrator within three (3) business days. The Director must have at least five (5) years’ experience working as a utilization management manager or specialist for a Medicaid program, be a registered nurse (RN) or Licensed Clinical Social Worker (LCSW) in West Virginia and be based in West Virginia.
7. The Care Management (CM) Director shall be responsible for overseeing the day-to-day operational activities of the Care Management Program in accordance with state guidelines. The CM Director is responsible for ensuring the functioning of care management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring, and evaluating). The CM Director shall have experience in the activities of care management as specified in 42 CFR §438.208. The Director must have at least five (5) years’ experience working as a case manager or care coordinator for a Medicaid program, be a West Virginia licensed registered nurse (RN) or a West Virginia licensed independent social worker with a demonstrated ability to communicate with members who have complex medical needs and may have communication barriers. The Director must be based in West Virginia.
8. The Behavioral Health (BH) Medical Director must employ or contract with an independent, active, and unrestricted West Virginia medical license in a related behavioral health specialty. The BH Medical Director must have at least five (5) years’ experience in serving as BH Lead or expert for a Medicaid program and five (5) years’ experience working in BH clinical care, including substance use. The BH Medical Director shall demonstrate knowledge of West Virginia’s overall BH system, which includes mental health, alcohol and drug addiction, and developmental disabilitiesdisabilities services. He or she shall be responsible for the daily operational activities of BH services across the full spectrum of care to members, inclusive of mental health and substance use services.
9. The Quality Director shall be responsible for oversight of the quality assurance program and related activities. The Director develops, administers, and oversees the quality assessment and performance improvement (QAPI) program, oversees and supports accreditation activities, and oversees and participates in the QAPI Committee. The Director initiates and maintains quality improvement projects that focus on one or more quality indicators, develops an approach to monitor provider performance, in collaboration with Network and Provider Relations staff, and engages in activities related to APMs as they related to quality-of-care measures and performance indicators. The Director must have at least five (5) years’ experience in overseeing a Medicaid quality program, either with an MCO, a state Medicaid agency or an external quality review organization (EQRO), a bachelor’s degree or higher and be based in West Virginia.
10. The Member Services Director is responsible for oversight of activities related to call center operations, enrollment and disenrollment activities, grievances, and other member- related inquiries and matters. The Director oversees the Member Services Department to assist members in obtaining covered services, interfaces with members and providers to handle questions and complaints, ensures that the member services phone line meets the minimum performance requirements and oversees the enrollment and onboarding activities of members. The Director must have at least three (3) years’ experience working with the public in an educational capacity on health insurance-related matters and experience working in or overseeing a call center. The Director must have a bachelor’s degree or higher and be based in West Virginia.
11. The Claims Payment Director is responsible for oversight of all physical and behavioral health claims payment- and encounter-related activities. The Director shall ensure timely and accurate payment of provider claims for physical and behavioral health services, and in general monitors claims processing activities for these services and oversees the reprocessing of claims due to rate changes or claims resubmissions. The Director must have at least three (3) years’ experience in claims processing and encounters with a health insurer, a bachelor’s degree or higher and is based in West Virginia.
12. The Network Development Director is responsible for network development and contracting activities for physical and behavioral health services. The Director establishes and maintains the provider network in geographically accessible locations for the population and ensures sufficient provider contracts for physical and behavioral health services to maintain access to care in accordance with BMS’s Medicaid and WVCHIP managed care network requirements. The Director facilitates physical health and behavioral health provider contracting activities, including creative payment arrangements and APMs, oversees physical health and behavioral health provider contracting documents and addenda and supports the oversight of physical health and behavioral health provider credentialing activities. The Director must have at least five
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Key Staff Requirements. The MCO’s Key Staff must also meet the following requirements, as applicable:
1. The Chief Executive Officer/Chief Operating Officer (CEO/COO) or West Virginia MHT Vice President/Senior Vice President shall serve in a full time (forty [40] hours per week) position available during BMS business hours to fulfill the responsibilities of the position and to oversee the entire operation of the MCO. The CEO/COO or West Virginia MHT Vice President/Senior Vice President shall devote sufficient time to the MCO’s operations to ensure adherence to program requirements and timely responses to BMS. The CEO/COO or West Virginia MHT Vice President/Senior Vice President shall be authorized and empowered to make contractual, operational, and financial decisions for the contract, related to business, claims payment, provider relations/contracting, and all other functions of the MCO. The CEO/COO or West Virginia MHT Vice President/Senior Vice President must be directly employed by the MCO. The CEO/COO or West Virginia MHT Vice President/Senior Vice President must attend in person, upon BMS request, meetings, and hearings of legislative committees, interested governmental bodies, agencies, and officers. The CEO/COO or West Virginia MHT Vice President/Senior Vice President must establish and maintain positive client relationships, make contractual, operational, and financial decisions on behalf of the MCO, and oversee and provider overarching contract oversight for the MCO. The CEO/COO or West Virginia MHT Vice President/Senior Vice President must have at least ten (10) years’ experience in Medicaid managed care oversight and operations, ten (10) years’ experience in healthcare administration and operations, a bachelor’s degree or higher and be based in West Virginia.
2. The Contract Liaison/MHT Administrator is responsible for overall delivery of the project, serving as a liaison with BMS during all phases of the contract. The Administrator must attend in person, upon BMS request, meeting and hearings of legislative committees and interested governmental bodies, agencies, and officers. The Administrator must maintain a positive client relationship, provide timely and informed responses to operational and administrative inquires that arise, meet with BMS staff or such other persons as designated by BMS on a regular basis to provide oral and written status reports and other information as required. The Administrator must respond to issues involving information systems and reporting, appeals, quality improvement, member services, service management, pharmacy management, medical management, and care coordination. The Administrator must ensure that each member has an ongoing source of care appropriate to his or her needs and a person or entity formally designated as primarily responsible for coordinating the services accessed by the member, per 42 CFR §438.208(b)(1). The Administrator must have at least five (5) years’ experience in Medicaid managed care contract oversight and five (5) years’ experience in healthcare, experience working with low-income populations, and cultural sensitivity, and a bachelor’s degree or higher and be based in West Virginiahigher.
3. The Chief Financial Officer (CFO) is responsible for oversight of all financial activities of the project. The CFO must oversee the MCO’s provider payment arrangements, including Alternative Payment Models (APMs), sign data certification forms, including, at a minimum, all encounter data and financial data and reporting for payments to contracted providers, and certified payment information to be utilized for rate-setting purposes or any payment-related data required by the Department. The CFO must have at least five (5) years’ experience serving as a financial lead for a managed care entity or other health insurance provider and a bachelor’s degree or higher.
4. The Compliance Officer is responsible for all compliance-related activities, including developing and implementing policies, procedures, and practices designed to ensure compliance with the requirements of this contract, and State and federal regulations. The Compliance Officer shall report directly to an Executive Compliance Officer at the corporate level of the organization and indirectly to the CEO/COO. The Compliance Officer will serve as the primary contact person for all BMS MHT compliance requests and concerns. The Compliance Officer must have at least five (5) years’ experience serving as a compliance officer or lead in the healthcare industry for a Medicaid managed care or other healthcare entity, a bachelor’s degree or higher and be based in West Virginia.
5. The Medical Director, who is a physician with a current, unburdened license through the West Virginia State Medical Board, shall have at least three (3) years of training in a medical specialty. The Medical Director shall devote full time (a minimum of thirty-two [32] hours per week) to the MCO’s operations to ensure timely medical decisions, including after-hours consultation as needed. The Medical Director shall be actively involved in all major clinical and quality management components of the MCO. The Medical Director must have at least five (5) years’ experience in serving as Medical Director for a Medicaid and/or commercial insurance program and five (5) years’ experience working in adult or pediatric primary care, an active West Virginia Medical License and be based in West Virginia.
6. Medical The Utilization Management Director is responsible for oversight of utilization management activities of the project, including oversight and management of processing referrals and pre-authorization requirements, as well as familiarity with appeals procedures. The Director must respond to requests from the BMS’s Medical Director or Contract Administrator within three (3) business days. The Director must have at least five (5) years’ experience working as a utilization management manager or specialist for a Medicaid program, be a registered nurse (RN) or Licensed Clinical Social Worker (LCSWLSW) in West Virginia and be based in West Virginia.
7. The Care Management (CM) Director shall be responsible for overseeing the day-to-day operational activities of the Care Management Program in accordance with state guidelines. The CM Director is responsible for ensuring the functioning of care management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring, and evaluating). The CM Director shall have experience in the activities of care management as specified in 42 CFR §438.208. The Director must have at least five (5) years’ experience working as a case manager or care coordinator for a Medicaid program, be a West Virginia licensed registered nurse (RN) or a West Virginia licensed independent social worker LSW with a demonstrated ability to communicate with members who have complex medical needs and may have communication barriers. The Director must be based in West Virginia.
8. The Behavioral Health (BH) Medical Director must employ or contract with hold an independent, active, active and unrestricted West Virginia medical license in as a related behavioral health specialtypsychiatrist. The BH Medical Director must have at least five (5) years’ experience in serving as BH Lead or expert for a Medicaid or commercial insurance program and five (5) years’ experience working in BH clinical care, including substance use. The BH Medical Director shall demonstrate have experience in and knowledge of West Virginia’s overall BH system, which includes mental health, alcohol and drug addiction, and developmental disabilitiesdisabilities services.
9. The Quality Director shall be responsible for oversight of the quality assurance program and related activities. The Director develops, administers, and oversees the quality assessment and performance improvement (QAPI) program, oversees and supports accreditation activities, and oversees and participates in the QAPI Committee. The Director initiates and maintains quality improvement projects that focus on one or more quality indicators, develops an approach to monitor provider performance, in collaboration with Network and Provider Relations staff, and engages in activities related to APMs as they related to quality-of-care measures and performance indicators. The Director must have at least five (5) years’ experience in overseeing a quality program, either with an MCO, a state Medicaid agency or an external quality review organization (EQRO), and a bachelor’s degree or higher.
10. The Member Services Director is responsible for oversight of activities related to call center operations, enrollment and disenrollment activities, grievances, and other member- related inquiries and matters. The Director oversees the Member Services Department to assist members in obtaining covered services, interfaces with members and providers to handle questions and complaints, ensures that the member services phone line meets the minimum performance requirements and oversees the enrollment and onboarding activities of members. The Director must have at least three (3) years’ experience working with the public in an educational capacity on health insurance-related matters and experience working in or overseeing a call center. The Director must have a bachelor’s degree or higher.
11. The Claims Payment Director is responsible for oversight of all physical and behavioral health claims payment- and encounter-related activities. The Director shall ensure timely and accurate payment of provider claims for physical and behavioral health services, and in general monitors claims processing activities for these services and oversees the reprocessing of claims due to rate changes or claims resubmissions. The Director must have at least five (5) years’ experience in claims processing and encounters with a health insurer.
12. The Network Development Director is responsible for network development and contracting activities for physical and behavioral health services. The Director establishes and maintains the provider network in geographically accessible locations for the population and ensures sufficient provider contracts for physical and behavioral health services to maintain access to care in accordance with BMS’s Medicaid and WVCHIP managed care network requirements. The Director facilitates physical health and behavioral health provider contracting activities, including creative payment arrangements and APMs, oversees physical health and behavioral health provider contracting documents and addenda and supports the oversight of physical health and behavioral health provider credentialing activities. The Director must have at least five
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