Senior Manager, Managed Care Initiatives

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-functiona