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Career Story: Hearing Officer For A State Medicaid Office

Hearing Officer For A State Medicaid Office

Job Title: Hearing Officer

Type of Company: I work for the state office of Medicaid (MassHealth).

Education: BA in Sociology, UMass •• JD from Northeastern University School of Law

Previous Experience: I worked as disciplinary counsel for the Board of Nursing, then Prosecuting Counsel for the Division of Professional Licensure and then Assistant Attorney General.

Job Tasks: I hold hearings on MassHealth issues that are appealed, such as terminations or denial of coverage, disability determinations, denial of prior authorization requests, and provider issues. For example, if a family is denied MassHealth because of their income, they may appeal the decision and they will have a hearing before me. I write the decisions and publish them. My decisions are appealable to the Superior Court.

On a typical day, I have 12 hearings scheduled. Routinely, several appellants fail to attend. This could be because the issue has been resolved, that the appellant understands why MassHealth took the action it did and they no longer dispute it, or they forget their appointment. The hearings are scheduled to take place in 15 - 60 minute increments, depending on the anticipated complexity of the matter. Generally, the shorter hearings are resolved by the appellant providing information that changes the determination, such as recent pay stubs, or other information that makes him/her eligible, for example, testimony that they no longer work.

Some hearings are much more complex. When an elderly person applies to MassHealth for nursing home care, their finances are scrutinized by MassHealth for the prior 60 months. Any transfers of resources must be looked at to determine whether they are permissible transfers or transfers that are disqualifying, and result in a penalty period of ineligibility. Those decisions are appealable and very often the appellants hire attorneys to argue "loopholes" in the regulations.

Best and Worst Parts of the Job: I enjoy meeting people and providing them with a direct answer to their questions about MassHealth. At times it is not the answer they want, but it is the correct answer.

However, sometimes I am overwhelmed with the writing portion of the job. At times I have as many as 20 decisions waiting to be written.

Job Tips: I would advise someone who is interested in my career to work with the public, take classes in administrative law and health care law. Also to read administrative decisions. It is always helpful to take classes in law school like civil trial practice where the student is forced to prepare, argue, and interact with witnesses.

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