Behavioral Health Program Manager

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.

• 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

• 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.
• Abi…