Program Integrity Director Jobs (NOW HIRING)

MassHealth is the Medicaid and CHIP plan for Massachusetts, providing access to healthcare services to approximately 2 million low-income and disabled residents of the Commonwealth. MassHealth is responsible for a ~$22 billion annual budget comprised of insurance premiums, payments for healthcare services, payments for pharmaceutical therapies, administrative expenses, and more.

The Program Integrity Unit is a highly strategic function within MassHealth that sets the standard for financial stewardship. Program Integrity leads and coordinates efforts related to identifying, preventing and mitigating fraud, waste and abuse (FWA) across the MassHealth program and ensuring Commonwealth resources are utilized appropriately in support of MassHealth members. The team is led by the Director of Program Integrity, who reports to the Deputy Medicaid Director, and consists of 13 internal staff members and dozens of contractors ($50M in annual contract value). MassHealth currently works in a hybrid in-person and virtual environment, with headquarters located in downtown Boston.

MassHealth is seeking qualified applicants for the position of Senior Manager, Managed Care Initiatives. Reporting to the Director of Managed Care Integrity, the Senior Manager is responsible for managing high priority projects related to MassHealth's efforts to identify, mitigate, and prevent provider and member fraud, waste, and abuse across the agency's programs with specific focus on managed care. This focus will include oversight of managed care entities' enforcement of program requirements for provider networks as well as other strategic priorities within managed care integrity and program integrity more broadly.

The Senior Manager will manage cross-functional teams across MassHealth policy and operations to develop work plans, generate innovative program integrity ideas, conduct analyses, and propose solutions to the MassHealth executive team. In addition, the Senior Manager will oversee program integrity vendor audit and analytic activities, ensuring vendor deliverables are delivered on time, accurate and meet MassHealth's expectations. The Senior Manager will regularly engage in communication and coordination with MassHealth managed care entities to support and monitor their program integrity operations. Finally, this position will entail consultation and coordination with senior leaders at MassHealth, including developing executive-level presentations of program integrity projects, deliberating on strategic goals, and reporting on key performance indicators. 

Program integrity is a top priority for MassHealth and EOHHS, and this role will drive key initiatives that directly serve that priority; as a result, the Senior Manager will have regular exposure to MassHealth and EOHHS senior leadership.

Duties and Responsibilities (these duties are a general summary and not all inclusive):

Manage cross-functional teams and projects including representatives from program teams, policy, strategy, analytics, and legal, as well as program integrity vendors, to execute develop, refine and implement managed care program integrity initiatives.

Engage with analytic resources to develop reports identifying aberrant provider billing patterns and overpayments within prioritized provider program areas.

Collaborate across MassHealth teams to develop external facing materials communicating MassHealth program integrity priorities and processes.

Assist in operational contract management of multiple Program Integrity vendors including tracking and managing timelines for vendor workstreams and deliverables.

Assist with cross-functional efforts identified by Program, Finance, and Strategy teams to implement policy and regulation changes.

Respond to urgent agency, legislative or regulatory priorities as identified.

Preferred Qualifications:

Excellent analytical and problem-solving skills.

Excellent MS Excel and PowerPoint skills.

Excellent communication skills.

Experience analyzing large data sets and/or providing business requirements to analytics teams.

Ability to work effectively under high pressure and tight deadlines.

Ability to provide structure and process management to projects.

Strong interpersonal skills.

Experience in health policy strongly preferred.

Knowledge of CMS, MassHealth, managed care, and 1115 waiver policy and regulations preferred.

Experience with claims data or other related analytical experience preferred.

Demonstrated performance in strategic planning and analysis.

About MassHealth:

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

For more information about our agency and programs please visit: https://www.mass.gov/orgs/masshealth

To 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.

Pre-Offer 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."

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.

ADA Reasonable Accommodation:

If you require a reasonable accommodation with the application/interview process, please contact us at: EOHHS Candidate ADA Requests.

For questions, please contact the Executive Office of Health and Human Services Human Resources at 1-800-510-4122 and select option #4.

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.

Salary placement is determined by a combination of factors, including the candidate's years of directly related experience and education, and alignment with our internal compensation structure as set forth by the Human Resources Division's Hiring Guidelines. For all bargaining unit positions (non-management), compensation is subject to the salary provisions outlined in the applicable collective bargaining agreement and will apply to placement within the appropriate salary range.

Comprehensive Benefits

When you embark on a career with the Commonwealth, you are offered an outstanding suite of employee benefits that add to the overall value of your compensation package. We take pride in providing a work experience that supports you, your loved ones, and your future.

Want the specifics? Explore our Employee Benefits and Rewards!

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

The Commonwealth is an Equal Opportunity Employer and does not discriminate on the basis of race, religion, color, sex, gender identity or expression, sexual orientation, age, disability, national origin, veteran status, or any other basis covered by appropriate law.  Research suggests that qualified women, Black, Indigenous, and Persons of Color (BIPOC) may self-select out of opportunities if they don't meet 100% of the job requirements.  We encourage individuals who believe they have the skills necessary to thrive to apply for this role.