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State of Massachusetts Senior Manager, Provider Integrity and Operations in Boston, Massachusetts

The Senior Manager of Provider Program Integrity reports to the Director of Provider Integrity and is responsible for managing high priority projects related to provider fraud, waste, and abuse. The Senior Manager directly supervises the Provider Program Integrity Business Analyst and two Senior Business Analysts. The Senior Manager oversees vendor contracts, helping with MassHealth’s efforts to control fraud, waste and abuse across the agency’s programs. The Senior Manager is responsible for developing and implementing performance standards and holding contracted vendors accountable. The Senior Manager is also responsible for ensuring that vendors and staff deliverables are timely, accurate and of the highest quality. The Senior Manager will also be expected to participate as a thought leader in program restructuring, ensuring regulation and policy changes are made with program integrity in mind. In addition, the team will work towards the identification of innovative program integrity solutions to achieve the agency’s dual priorities of maintaining high-quality member care and controlling spending growth.

The Senior Manager is a subject matter expert in MassHealth provider and payment policies, procedures and regulations, as well as supporting systems (HIX, MA-21, MMIS, and Cognos). The Senior Manager will also act as a consultant and advisor to senior leaders at MassHealth to provide feedback on the issues and concerns identified which may entail a new MMIS edit, a regulation/policy change, or a new operational process.

The Senior Manager of Provider Program Integrity oversees high-priority, inter-departmental projects including 1) restructuring of provider regulations, 2) identification and implementation of operational improvements, 3) identification and implementation of program integrity solutions, and 4) other urgent program integrity priorities. For each such initiatives, the Manager works with the Director of Provider Program Integrity and Analytics Manager and will oversee a cross-functional team including representatives from MassHealth program, policy, legal, and IT units to develop work plans, generate innovative program integrity ideas, conduct analysis, and propose solutions to the MassHealth executive team. The Manager of Program Integrity will also focus expanding analytic capabilities within the Program Integrity Unit and identifying new ways of reporting fraud, waste, and abuse across MassHealth programs. The Manager also engages with external stakeholders, MassHealth members, advocates, providers, and payers, as necessary to collect input and ensure policy objectives are implemented smoothly.

_Duties and Responsibilities (these duties are a general summary and not all inclusive)_

  • Manage cross-functional teams including representatives from program, policy, and legal to execute PI initiatives (e.g. Implement algorithms into Pre-Pay edit system). Communicate findings to Provider Program Integrity Director.

  • Develop and manage Program Integrity budget tracker. Work with the Provider Program Integrity Director and Program Integrity Director to set annual goals for cost savings and communicate quarterly status updates across teams to executive team.

  • Work with Program Integrity Analytics team to monitor aberrant growth amongst provider types in encounter data. Work with contract managers to identify new potential PI initiatives.

  • Assist with cross-functional efforts identified by Finance and Strategy teams to implement policy and regulation changes. Communicate work flow to leadership.

  • Conduct analyses on medical claims data, provider cost reports, and other sources to identify and prioritize opportunities for improvement (e.g., high-growth provider types, high-utilizing members).

  • Respond to urgent legislative or regulatory priorities as identified.

*Preferred Qualifications*:

  • Exceptional analytical and problem-solving skills

  • Experience in healthcare preferred

  • At least four (4) years of professional experience at a top-tier consulting firm or in an equivalent analytical role

  • Management experience.

  • Exceptional MS Excel and PowerPoint skills

  • Contract Management

_T__O APPLY:_

Please upload both Resume and Cover Letter for this position when applying. First consideration will be given to those applicants that apply within the first 14 days.**

_About MASSHEALTH:_

MassHealth, the Commonwealth’s Medicaid program, provides health care benefits to certain low and medium-income Massachusetts residents. As an innovative national leader, the Commonwealth’s Medicaid program offers the opportunity to work with state-of-the-art technologies in a cutting-edge, fast-paced, call center environment. Selected applicants will have exceptional customer service, communications, and analytical skills. We offer a unique opportunity to serve, and to make a positive contribution to our members.

The mission of MassHealth is to improve the health outcomes of our diverse members, their families and their communities by providing access to integrated health care services that sustainably promote health, well-being, independence and quality of life.

For more information about our agency and programs please visit:_ _www.mass.gov/masshealth

Special Requirements:

Based on assignment, possession of a current and valid Massachusetts Class D Motor Vehicle Operator’s license or the equivalent from another state may be required.

_Total Compensation:_

As an employee of the Commonwealth of Massachusetts, you are offered a great career opportunity influencing a wide-spectrum of services to the diverse populations we serve - but it's more than a paycheck. The State's total compensation package features an outstanding set of employee benefits which you should consider towards your overall compensation, including:

  • 75% state paid medical insurance premium

  • Reasonable Dental and Vision Plans

  • Flexible Spending Account and Dependent Care Assistance programs

  • Low cost basic and optional life insurance

  • Retirement Savings: State Employees' Pension and a Deferred Compensation 457(b) plan

  • 11 paid holidays per year and competitive Sick, Vacation and Personal Time

  • Tuition Benefit for employee and spouse at state colleges and universities

  • Short-Term Disability and Extended Illness program participation options

  • Incentive-based Wellness Programs

  • Professional Development and Continuing Education opportunities

  • Qualified Employer for Public Service Student Loan Forgiveness Program

_Pre-Hire Process_*: *

A criminal and tax history background check will be completed on the recommended candidate as required by the regulations set forth by the Executive Office of Health and Human Services prior to the candidate being hired. For more information, please visit http://www.mass.gov/hhs/cori and click on "Information for Job Applicants."

As part of the hiring process, the Office of Human Resources will be verifying any college-level degrees conferred to the selected candidate. Additionally, any licensure required for the position will be verified. Information provided as part of the hiring process is subject to the Massachusetts Public Record Law and may be published on the Commonwealth’s website.

Education, licensure and certifications will be verified in accordance with the Human Resources Division’s Hiring Guidelines.

  • Education and license/certification information provided by the selected candidate(s) is subject to the Massachusetts Public Records Law and may be published on the Commonwealth’s website.

For questions, please contact the Executive Office of Health and Human Services Human Resources Department at 1-800-510-4122 and select option #2.

MINIMUM ENTRANCE REQUIREMENTS:

Applicants must have at least (A) five (5) years of full-time or, equivalent part-time, professional, professional internship, administrative, supervisory, or managerial experience in business administration, business management, public administration, public management, clinical administration or clinical management or (B) any equivalent combination of the required experience and substitutions below.

Substitutions:

I. A certificate in a relevant or related field may be substituted for one (1) year of the required experience.

II. A Bachelor’s degree in a related field may be substituted for two (2) years of the required experience.

III. A Graduate degree in a related field may be substituted for three (3) years of the required experience.

IV. A Doctorate degree in a related field may be substituted for four (4) years of the required experience.

An Equal Opportunity / Affirmative Action Employer. Females, minorities, veterans, and persons with disabilities are strongly encouraged to apply.

Job: *Administrative Services

Organization: *Exec Office Of Health and Human Services

Title: Senior Manager, Provider Integrity and Operations

Location: Massachusetts-Boston-1 Ashburton Place

Requisition ID: 200006XP

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