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Due to the increased membership in Medicare Advantage, additional staff is needed.

Job Summary:

The Behavioral Health (BH) Program Manager is responsible for the development and implementation of policies and procedures that measure the adherence of the health plan’s BH clinical programs to CMS and/or Executive Office for Health and Human Services (EOHHS) for regulations for Medicare and Medicaid plans. This will include, but is not limited to, setting up monitoring and adherence protocols that CMS requires for clinical programs, as well as identifying, developing, executing all internal audit and mental health parity requirements, and participating in external auditing as indicated. The BH Program Manager will identify barriers and leverage strengths throughout the company to ensure the Mass General Brigham Health Plan BH clinical programs meet or exceed all state and federal requirements and will act as a subject matter expert on such topics as mental health, clinical audit programs, and the interpretation of rules and regulations both at the state and federal level. This person will collaborate with the legal, regulatory affairs, and compliance departments to ensure regulations are interpreted consistently very closely to ensure the programs are socialized and vetted at the appropriate committees. This position will work collaboratively with other departments within Mass General Brigham Health Plan (i.e., IT, Clinical, LRAC, Finance, and Quality) to support the functions and operations of Behavioral Health clinical initiatives as well as performance evaluation and reporting activities.

Essential Functions
-Ensures BH clinical and operational compliance with all state and federal Medicare and/or Medicaid regulations including but not limited to CMS Annual Final Rule requirements, Advancing Interoperability & Prior Authorization, letter and reporting templates, etc.
-Responsible for oversight and auditing of all BH Medicare reporting (e.g., ODAG, Part-C, HSD reporting, First Tier, Downstream, and Related Entities (FDRs) monitoring, etc.) – including reporting results out to key stakeholders and assisting with identifying and implementing corrective action plans when deficiencies are noted
-Acts as the point of contact for all BH member and provider issues including escalations – this includes both clinical and operational escalations
-In collaboration with the Compliance department, develops Corrective Action Plans when issues with non-compliance are identified and work collaboratively to resolve all deficiencies within the timeline established
-Conducts analysis and evaluation through monitoring data (i.e., outcomes, cost, and utilization).
-Supports clinical initiatives as needed. Completes data analysis when appropriate.
-Performs program evaluation as indicated.
-Makes recommendations to the Steering Committee based on oversight activities.
-Anticipates and meets, or exceeds, internal and/or external customer expectations and requirements; establishes and maintains positive relationships with customers and gains their trust and respect.
-Holds self and others accountable to meet commitments.
-Persists in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
-Builds positive relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
-Performs other duties as assigned
-Complie with all policies and standards

• Qualifications Qualifications

• Master's degree required

• LICSW, LMHC, or LMFT preferred

• At least 5-7 years of directly related Medicare and/or Medicaid health insurance experience required

• At least 3-5 years of compliance experience – operating within a compliance framework to read, understand, operationalize and oversee adherence to regulatory requirements required

• At least 2-3 years of managed care, managed behavioral healthcare or service delivery experience, including data analysis and reporting processes required

• At least 2-3 years of CMS/Medicare auditing experience preferred

• At least 2-3 years of mental health parity experience preferred

• Knowledge, Skills, and Abilities

• CMS/Medicare auditing

• Excellent communication skills, both written and oral.

• Ability to multitask and prioritize.

• Ability to work in a team environment.

• Ability to work with external partners, including community-based provider groups.

• Knowledge of healthcare delivery systems for both Medicaid and commercial populations.

• Demonstrate Mass General Brigham Health Plans' core brand principles of always listening, challenging conventions, and providing value.

• Bring fresh ideas forward by listening to and working with employees and the people we serve.

• Respect the talent and unique contributions of every individual

• Strong, demonstrated track record of ability to execute on time, on budget, and on scope.

• Strong aptitude for technology-based solutions.

• Ability to inject energy, when and where it’s needed.

• Current in healthcare trends.

• Demonstrated forward, visionary thinking; ability to see “what is” and envision “what could be.”

• Ability to develop, introduce, defend, and gain support for new ideas and approaches.

• Excellent leadership skills and leadership track record.

• Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience, strong executive presence, presentation, and communication skills.

• Strong verbal, active listening, and written communication skills required.

• Ability to view the long-range trends and cycles of the business and industry and see the “big picture.”

• Ability to apply a variety of strategic frameworks to analyze problems and to guide and develop solutions.

• Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy.

• Excellent interpersonal skills, including the ability to influence others at all levels of an organization.

• Additional Job Details (if applicable)Working Conditions

• This is a remote role but there will be intermittent needs to go to the office at Assembly Row in Somerville, MA up to 1x/month

Remote Type
Remote

Work Location
399 Revolution Drive

Scheduled Weekly Hours:

40

Employee Type
Regular

Work Shift
Day (United States of America)

Pay Range
$79,560.00 - $115,720.80/Annual

Grade
7

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

EEO Statement: 8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.