Adult Day Health and Day Habilitation MassHealth Program Specialist

State of Massachusetts Boston, MA
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.

MassHealth is the Medicaid and SCHIP plan for Massachusetts, providing healthcare services to 1.9 million low-income and disabled residents of the Commonwealth. MassHealth is responsible for a $15 billion annual budget comprised of premiums to insurance providers, direct payments to healthcare providers, and administrative expenses.

The MassHealth Office of Long Term Services and Supports (OLTSS) is responsible for managing a comprehensive system of care for elders and persons with disabilities. OLTSS manages a range of thirteen (13) Fee-For-Service (FFS) programs including Hospice, Home Health, Independent Nursing, Therapies, DMEPOS (Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment, Prosthetics and Orthotics), Personal Care Attendant (PCA), Early Intervention, Adult Foster Care (AFC), Group Adult Foster Care (GAFC), Adult Day Health (ADH), Day Habilitation, Nursing Facilities, and Chronic-Disease Rehabilitation Hospitals. There are approximately 1,500 providers in the FFS network.

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

Day-to-Day Operational Duties:

* Day-to-day monitoring of the OLTSS Third Party Administrator (TPA) contractual functions relating to provider enrollment and credentialing, claims operations, prior authorization, appeals, program integrity and reporting related to the ADH/DH programs, and ability to triage issues to the appropriate OLTSS internal staff.

* Provide assistance to ADH/DH program manager during program regulation and rate regulation development and implementation, including working with IT team and Claims operation team.

* Ensure provider compliance with all applicable program rules, regulations and subregulatory guidance including provider education, engagement and issue escalation.

* Provide assistance to ADH/DH program manager on provider and constituent affairs services to resolve program policy and service delivery issues.

* Assist with reviewing, filing, and following up on ADH/DH critical incident reports.

* Track and monitor multiple projects and initiatives relative to the programs, recommend changes in policy, communication strategies and/or program structure to the Program Manager, Assistant Director of Community Based Programs and other members of the OLTSS leadership team.

* Monitor, research and facilitate the resolution of provider payment and pended claim issues.

* Effectively communicate priority project statuses, risks and outstanding decisions to OLTSS and MassHealth leadership both verbally and in written form under quick timelines. Actively utilize, update and support project management tools and plans.

* Assist in the orientation and training of new program staff, and provide ongoing support and guidance to team members.

* Monitor TPA Board of Hearing (BOH) cases and collaborate with appropriate OLTSS internal staff.

* Provide program-related assistance to other units within the MassHealth, the Executive Office of Elder Affairs, and other agencies in the state government.

Program Integrity Duties:

* Conduct onsite visits with providers including but not limited to program audits, site reviews and provider education visits (limited travel required).

* Maintain databases and spreadsheets to provide current and accurate program and audit activities and follow-up on recommended corrective action or compliance issues raised in audits.

* Collaborate on TPA program integrity (PI) responsibilities and serve as the program integrity specialist for these programs including Audits, algorithm development and deployment and other PI activities.

Additional Duties:

* Assist ADH/DH program manager in working with provider stakeholder groups as needed.

* Work with MassHealth members/family to resolve issues that relate to the ADH/DH provider network and respond to requests for information regarding payment and policy questions.

* Work with the Department of Public Health (DPH) concerning any licensure issues for ADH providers.

* Collaborate with the Strategic Initiatives team in the management of all relevant TPA functions.

* Collaborate with finance and strategy on budget, cost reports, rate setting and modeling.

* Collaborate with the OLTSS External Affairs team on drafting talking points, policies, memoranda, and meeting materials.

Preferred Qualifications:

* Knowledge and experience in LTSS program policy development, analysis and evaluation.

* Possess an understanding of the role of data and analysis in driving system change.

* Ability to develop and maintain effective working relationships with a range of LTSS stakeholders, partners, and MassHealth members.

* Knowledge of the Massachusetts health care industry and market dynamics related to LTSS.

* Knowledge and experience in program and/or provider audits.

* Proficiency in Microsoft Excel, Word, and PowerPoint; knowledge of Microsoft Project and Visio is a plus.

* Knowledge of payment reform and care delivery reform strategies, including an understanding of the relationship between payment reforms, delivery system change, quality improvement and customer satisfaction in LTSS.

* Ability to understand, apply and explain pertinent laws, rules, regulations, policies and procedures.

* Knowledge of the methods used in the preparation of charts, graphs and tables, and of the methods of general report writing.

* Ability to analyze and determine the applicability of data, to draw conclusions and to make appropriate recommendations.

* Ability to gather and assemble information in accordance with established procedures, to compile statistical data and to communicate clearly, concisely, logically, accurately and persuasively in written, verbal and visual formats in internal, external and public settings.

* Ability to work independently and collaboratively.

* Ability to manage time and set priorities and reach decisions under pressure.

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.

Pre-Hire Process:

A criminal 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 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.

For questions, please contact the CYF Office of Human Resources at 1-800-510-4122 and select option #2

First consideration will be given to those applicants that apply within the first 14 days.

MINIMUM ENTRANCE REQUIREMENTS: Applicants must have at least (A) four years of full-time, or equivalent part-time, professional, administrative or managerial experience in business administration, business management or public administration the major duties of which involved program management, program administration, program coordination, program planning and/or program analysis, and (B) of which at least one year must have been in a supervisory capacity, or (C) any equivalent combination of the required experience and the substitutions below.


I. A Bachelor's degree with a major in business administration, business management or public administration may be substituted for a maximum of two years of the required (A) experience.*

II. A Graduate degree with a major in business administration, business management or public administration may be substituted for a maximum of three years of the required (A) experience.*

III. A Bachelor's or higher degree with a major other than in business administration, business management or public administration may be substituted for a maximum of one year of the required (A) experience.*

* Education toward such a degree will be prorated on the basis of the proportion of the requirements actually completed.

NOTE: No substitutions will be permitted for the required (B) experience.

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