SoundCloud

Consultant

• Provides orientation, training, guidance and direction, to Consultant Pharmacists and Pharmacy Associates
• Coordinates the request for prior authorization (RPA) process including the data entry and the generation of reports that stem from this process, as well as ensure compliance with the federal twenty-four hour time limit
• Participates in program planning and development
• Participates in the development of clinical drug use criteria for the prospective and retrospective review components of the DUR Program
• Researches member’s case and may represent the client during appeal processes regarding prescription medications
• Performs medication therapy management comprehensive and targeted medication reviews of medical and medication profiles
• Reviews member’s medical and medication profiles and interacts with health care providers and client members to review appropriate drug therapy
• Provide real-time drug therapy recommendations to prescribers
• Reviews clinical documentation submitted by treating physicians and pharmacists to determine medical necessity and program compliance
• Decides in real time via telephone communications with pharmacies the authorization or denial of prior approval requests for prescription medications
• Provides pharmaceutical expertise and knowledge to the advisory board’s clinical workgroups
• Monitors over-utilization and under-utilization of prescribed medicines for members
• Assists in monitoring and researching profiles for compliance on a daily basis
• Refers suspected abuse and fraudulent members to the program manager or designee for case review
• Participates in site visits to Provider offices, as necessary
• Participates in agency meetings as requested
• Leads and participates in quality improvement and quality assurance initiatives

Managed Care Consultant Pharmacist IV

• Participate in orientation and training of Consultant Pharmacist I staff.
• Review clinical documentation submitted by treating physicians and pharmacists to determine medical necessity and program compliance.
• Decide in real time via telephone communications with pharmacies the authorization or denial of prior approval requests for prescription medications.
• Provide pharmaceutical expertise and knowledge to advisory board clinical workgroups.
• Monitor over-utilization and under-utilization of prescribed medicines for members.
• Monitor and research member profiles for compliance on a daily basis.
• Refer suspected abuse and fraudulent members to program management or designee for case review.
• Participate in site visits to client offices, as necessary.
• Participate in quality improvement and quality assurance initiatives.
• Perform other duties as required.

Consultant Pharmacist II

• Provides orientation, training, guidance and direction to Consultant Pharmacists and Pharmacy Associates
• Coordinates the request for prior authorization (RPA) process, data entry, and report generation; ensures compliance with federal 24-hour time limit
• Participates in program planning, development, and development of clinical drug use criteria for DUR programs
• Researches member cases and may represent the client during appeal processes regarding prescription medications
• Performs medication therapy management comprehensive and targeted medication reviews of medical and medication profiles
• Reviews member medical and medication profiles and interacts with health care providers to review appropriate drug therapy
• Provides real-time drug therapy recommendations and decides authorization or denial of prior approval requests via telephone
• Provides pharmaceutical expertise to advisory board clinical workgroups and monitors over-utilization and under-utilization of medicines
• Participates in quality improvement and quality assurance initiatives and site visits to provider offices as necessary

Consultant Pharmacist IV

Data Analyst

• Manage financial models that determine how major segments of the MassHealth budget—such as provider payments, managed care funding, and other programmatic allocations—are distributed, and present recommendations to executive leadership including the Medicaid Director, Chief Financial Officer, and Chief of PCDI.
• Produce recurring analyses in Excel to support the development, execution, and monitoring of MassHealth financial performance, including revenue trends and expenditure changes.
• Collaborate with the MassHealth budget team, payment operations team, and program teams to ensure funding strategies are accurately reflected in the annual budget and operational systems.
• Conduct ad-hoc financial analyses to support targeted programmatic initiatives, such as evaluating payment models, enhancing provider incentives, or addressing cost/revenue variances.
• Assist in preparing presentations and reports for executive leadership and external stakeholders on key financial decisions, including budget levels, trends, and policy rationale.
• Contribute to federal documentation efforts (e.g., CMS submissions), including coordinating internal reviews, drafting responses to federal questions, tracking follow-up items, and supporting contract-related deliverables.
• Facilitate meetings and communications across departments to maintain alignment on timelines, financial strategies, and key decisions.
• Support agency-wide initiatives, ensuring appropriate fiscal tracking and communication across program teams.
• Serve as a liaison for internal data visualization efforts (e.g., Tableau dashboards), providing input on design, functionality, and usability to ensure alignment with finance-related goals.

Financial Data Analyst

Program Manager

• Collaborate with the Director and MassHealth program teams on development of strategy and design of quality programs for behavioral health providers, Integrated Care Programs, and acute hospitals.
• Develop program elements including selection of quality and health equity measures, setting performance targets, performance assessment methodologies, and maintaining contractual/regulatory documents.
• Act as a subject matter expert on quality improvement, quality measurement, and evaluation; provide consultation and leadership to MassHealth and OCA program staff.
• Maintain knowledge of national quality initiatives and establish linkages within OCA, MassHealth, and UMass Chan departments to develop and staff quality projects.
• Manage day-to-day logistics and operational needs of the program; convene and provide direction to program teams; coordinate communications and meetings among senior leadership.
• Represent the Quality Office at state, regional, and national levels as directed.
• Hire, supervise, and evaluate staff; provide functional supervision to project/program staff as needed.
• Review and monitor compliance with federal and state regulations and perform other duties as required.

Program Manager, Quality

• Collaborate with the MassHealth Chief Medical Officer, MassHealth Quality Office, and MassHealth program teams on strategy and design of MassHealth health equity measurement and value-based care programs
• Develop program elements including selection of quality and health equity measures, setting performance targets, establishing and testing performance assessment methodologies, iterating on program design, reporting, evaluation, and performance management
• Support alignment of organization-wide equity initiatives with MassHealth strategic goals
• Manage health equity programs, including incentive programs for accountable care organizations and/or acute hospitals
• Act as a subject matter expert on equity measurement and equity improvement and maintain current knowledge of national quality and equity initiatives
• Support program evaluation and monitoring, vendor procurement, contracting, and vendor management
• Maintain and update contractual and regulatory documents and monitor compliance with federal and state regulations
• Establish and maintain linkages within OCA and MassHealth to support equity-related projects
• Provide strategic input and support for MassHealth program teams in designing and implementing equity improvement activities for providers
• Manage day-to-day logistics and operational needs including project management, convening, and materials preparation to ensure timely deliverables
• Represent MassHealth and OCA at the state, regional and national levels as directed
• Hire, advise, directly supervise and evaluate performance of other staff and provide functional supervision as needed
• Perform other duties as required.

Program Manager, MassHealth Equity Program

• Provides orientation, training, guidance and direction to Consultant Pharmacists and Pharmacy Associates
• Coordinates the request for prior authorization (RPA) process including data entry and generation of reports and ensures compliance with the federal twenty-four hour time limit
• Participates in prospective and retrospective drug utilization review (DUR) activities, including handling live calls from physicians and pharmacists
• Reviews member medical and medication profiles and provides medication therapy management comprehensive and targeted reviews
• Researches member cases and may represent the client during appeal processes regarding prescription medications
• Reviews clinical documentation to determine medical necessity and program compliance and decides authorization or denial in real time via telephone with pharmacies
• Participates in development of clinical drug use criteria and program planning
• Provides pharmaceutical expertise to advisory board clinical workgroups and monitors over-utilization and under-utilization of prescribed medicines
• Assists in monitoring and researching profiles for compliance daily and refers suspected abuse or fraudulent members for case review
• Participates in site visits to provider offices and agency meetings as requested
• Leads and participates in quality improvement and quality assurance initiatives
• May perform other job related duties as assigned or requested

• Collaborate with the MassHealth Chief Medical Officer, MassHealth Quality Office, and MassHealth program teams on strategy and design of health equity measurement and value-based care programs
• Develop program elements including selection of quality and health equity measures, setting performance targets, establishing and testing performance assessment methodologies, reporting, evaluation, and performance management
• Support alignment of organization-wide equity initiatives with MassHealth strategic goals
• Manage health equity programs, including incentive programs for accountable care organizations and/or acute hospitals
• Act as subject matter expert on equity measurement and equity improvement and maintain current knowledge of national initiatives
• Support program evaluation, monitoring, and compliance with federal and state regulations
• Oversee and/or support vendor procurement, contracting, and vendor management
• Maintain and update contractual and regulatory documents and establish linkages within OCA and MassHealth
• Provide strategic input and support for equity improvement activities for MassHealth providers
• Manage day-to-day logistics, project management, convening, and materials preparation to ensure timely deliverables
• Represent MassHealth and OCA at state, regional, and national levels as directed
• Hire, advise, directly supervise, and evaluate performance of other staff; provide functional supervision for project/program staff as needed
• Perform other duties as required.

Program Manager, Equity

• Participates in orientation and training of Consultant Pharmacist I staff.
• Reviews clinical documentation submitted by treating physicians and pharmacists to determine medical necessity and program compliance with increasing independence.
• Decides in real time via telephone communications with pharmacies the authorization or denial of prior approval requests for prescription medications.
• Provides pharmaceutical expertise and knowledge to advisory board’s clinical workgroups.
• Monitors over-utilization and under-utilization of prescribed medicines for members.
• Assists in monitoring and researching profiles for compliance on a daily basis.
• Refers suspected abuse and fraudulent members to program management or designee for case review.
• Participates in site visits to client offices, as necessary.
• Participates in quality improvement and quality assurance initiatives.
• Handles live calls from physicians and pharmacists to review drug therapy and determine approval or denial of real time prescriptions.

Paralegal

• Under the general direction of the Specialty Programs Unit Manager, serve as a resource to the Center for Healthcare Financing (CHCF) staff primarily in matters concerning estate recovery
• Ensure the integrity of collection outcomes, according to federal and state estate recovery regulations
• Refine and enhance current operations, implementing methods to identify new cases, verify claims and recover payments paid by Medicaid or other state funded programs
• Research, maintain and understand compilation of all Federal and State statutes and regulations pertaining to Third Party and Estate Recovery
• Maintain an assigned caseload following established protocols
• Identify benefits paid by Medicaid and calculate total value to be recovered in each case
• Represent the best interest of the Medicaid program consistent with CHCF goals and objectives
• Request and produce claims history printouts including all service reports from Medicaid history databases
• Investigate and document all case related matters and relevant financial and medical history to support claims against probate estates or third party settlements
• Provide training to support staff and maintain/update Recovery training manual
• Maintain all case records as required for established time periods
• Communicate and collaborate with probate courts, attorneys, hospitals, insurance companies and other relevant entities
• Conduct legal research using public databases and web applications and prepare legal memoranda for referral to Medicaid EHS legal department
• Research record of ownership and title of real estate at the Registry of Deeds
• Perform other job related duties as required or assigned

Paralegal - Case Specialist II, Estate Recovery Program

• Under the general direction of the Department Manager or designee, the Sr. Program Operations Specialist will be responsible for the categorization of time study data and review of expenditure and other data for the purpose of claim calculation and submission.
• Will work within the Federal Claiming unit that specializes in configuring technical solutions and providing expertise and resources to state government agencies for the purposes of seeking federal reimbursement for eligible expenditures and services. Currently this unit provides solutions and support to 23 programs in 9 states and over 50,000 end users.
• Note: Position is fully remote.
• Responsibilities Carefully evaluate and analyze RMTS data completed by clients to ensure compliance with program requirements.
• Promptly validate data with clients, as appropriate, to ensure accuracy of submitted information within time sensitive deadlines.
• Update internal knowledge database to continually refresh or improve performance and accuracy of work.
• Complete independent peer review of other RMTS program data to ensure categorization by peers aligns with internal processes and procedures.
• Collaborate with other team members and leverage team resources to categorize data consistently and timely.
• Provide constructive feedback as appropriate.
• Compile final RMTS results for client review and sign off, as required.
• Review and analyze expenditure and statistical data provided by clients to support claim and cost settlement calculations in accordance with internal processes and procedures.
• Participate in testing of system features/functions/bug fixes, including suggesting and identifying areas for functionality improvements.
• Keep abreast of any regulatory or program changes.

Senior Program Operations Specialist

• Develop and maintain data-driven financial, claim-related, and program performance reports for internal management and external client audiences.
• Perform compliance reviews of program data, including claims, payments, payment or costs settlement report data for quality assurance and program integrity purposes.
• Analyze large, complex data sets to quantify and resolve problems, inform management decisions, monitor program changes and their impact, and communicate important information for internal management and external clients.
• Apply knowledge of program systems to identify and troubleshoot issues, participate in testing of software changes and assist clients and external users to effectively use the program’s systems and applications.
• Assist in the design and maintenance of internal controls to ensure quality and accuracy of business unit’s work products.
• Compile and review claims, payments and/or other financial data for approval or distribution
• Identify and resolve any discrepancies, questions or outstanding issues related to claims, payments or other financial data for approval or distribution including coordination with internal staff, health plans, clients, or systems staff.
• Prepare financial/claims data for final submission and ensure the quality of the data is accurate and meets regulatory compliance, financial and/or other contractual requirements.
• Apply knowledge of state and federal program requirements, program guidelines and reimbursement methodologies in all aspects of work.
• Design and produce ad-hoc reports to meet internal management and client requests for data to inform decision-making and to fulfill public records requests.
• Complete and synthesize analysis of claims, payments and/other financial data to report to appropriate internal and external stakeholders.
• Utilize verbal and written communication skills to effectively communicate program information and explain requirements and methodology to various clients and external users of Umass Chan systems and applications.
• Complete tasks required for the preparation and conclusion of the program’s operational, financial or other contractual deadlines including set-up and maintenance of required claiming variables, notifications to clients and other stakeholders of deadlines, claim status, and actions needed.
• Preserve confidential, protected health and personally identifiable information and files.
• Perform related duties as needed and as assigned.

Healthcare Data Analyst

Financial Planning and Analysis

• The Financial Analyst will be responsible for conducting financial analysis, budgeting and planning, and the creation and presentation of financial statements, reports, and revenues, and reporting and metrics functions.
• The position will provide information to the leadership team on cost savings, cost analysis, financial management, financial metrics, and financial improvement opportunities.
• The Financial Analyst will also perform backfill support for data analysis needs.
• The Financial Analyst will report to the Director, Finance.
• Assist the Director, Finance in monitoring and analyzing financial accounts on a monthly, quarterly, and annual basis.
• Support the Finance leadership team in providing market and margin analysis, pricing models, and cost development support services.
• Analyze financial information using queries, spreadsheets, databases and other reporting tools for trend analysis, forecasting, and financial ratios.
• Analyze trends, make financial projections, and assess financial risk.
• Produce financial reports for management, as needed or requested, including income statements, cash flow statements, and balance sheets.
• Conduct in-depth analysis of program data and performing computations with a high degree of independence.
• Collect, extract, analyze, and manage financial information.
• Ensure accuracy of reports by reviewing data and resolving discrepancies internally for assigned reports.
• Prepare reports and projections based on financial data, consolidating for leadership team.
• Create and submit journal entries and reports.
• Track and analyze revenue data.
• Participate in project meetings related to financial analysis, data analysis, and management.
• Support internal dashboards and reporting, including the review of dashboards created by other team members.
• Review and support DCS finance group team members as needed.
• Review and monitor compliance with the federal and state regulations.

Financial Analyst

Medical Director

• The Medical Director provides clinical leadership for the Disability Evaluation Services (DES) Program, under the supervision of the Senior Medical Director.
• As part of the DES senior leadership team, the Medical Director reviews disability regulations, directs internal clinical procedures and provides consultation to state policy makers.
• The Medical Director is responsible for supervising and/or overseeing the physician advisors and quality assurance consultants as well as ensuring compliance for contracted network consultative examination providers.
• Major Responsibilities: At the direction of the Senior Medical Director, provides clinical leadership for the disability evaluation process; Provides leadership for the disability process for Medicaid agencies and Public Employees Retirement Systems; Monitors productivity and provides oversight and clinical direction to DES clinicians, including Physician Advisors; Participates in creation of physician compensation models in conjunction with leadership team; Leads Internal Clinical Consultation Committees for MassHealth, OCA (Office of Clinical Affairs), and other Pension Retirement Contracts, for the handling and decision making of contested cases; Assists in formulating and implementing new business development strategies and marketing and sales efforts to achieve growth aligned with the strategic priorities of UMass Chan and ForHealth Consulting; Collaborates with DES clinical leadership in the interpretation of disability regulations; Participates in the review of regulation and policy changes impacting the disability evaluation process; Leads the development of clinical procedural standards and quality evaluations; Monitors and provides feedback to DES physicians and psychologists; Oversees DES quality management programs, including ongoing quality assurance, program evaluation initiatives, and performance goal management; Provides feedback to DES physicians and psychologists as well as other DES clinical staff regarding clinical policies and the outcomes of quality evaluations; Participates in the development and training for network providers and DES clinical staff, including physicians and psychologists; Advises DES staff on client issues involving sensitive medical information, adverse clinical findings, and safety issues; Directs contract compliance initiatives for DES contracted network physicians and psychologists; In conjunction with the Physician Network Manager, contributes to the recruitment and credentialing of contracted network physicians and psychologists; Provides feedback, quality assurance and disciplinary process of DES contracted network physicians and psychologists; Under the direction of the Senior Medical Director, oversees new projects and initiatives at DES for MassHealth or other clients, and explores new business opportunities for DES.

Managed Care Consultant Pharmacist IV

Consultant Pharmacist II

Consultant Pharmacist IV

Financial Data Analyst

Program Manager, Quality

Program Manager, MassHealth Equity Program

Consultant Pharmacist IV

Program Manager, Equity

Consultant Pharmacist II

Paralegal - Case Specialist II, Estate Recovery Program

Senior Program Operations Specialist

Healthcare Data Analyst

Financial Analyst

Medical Director - Disability Evaluation Services (Remote)