Lead Program Integrity Consultant, Managed Care Organization (MCO) / Human Services Program Consultant

Working Title: Lead Program Integrity Consultant, Managed Care Organization (MCO)

Job Class: Human Services Program Consultant

Agency: Human Services Dept

• Job ID: 84072
• Location: St. Paul
• Telework Eligible: Yes
• Full/Part Time: Full-Time
• Regular/Temporary: Unlimited
• Who May Apply: Open to all qualified job seekers
• Date Posted: 02/11/2025
• Closing Date: 02/24/2025
• Hiring Agency/Seniority Unit: Human Services Dept / MAPE DHS Central Office
• Division/Unit: Department of Human Services (DHS) / Office of Inspector General (OIG) FFAID MCO Oversight
• Work Shift/Work Hours: Day Shift / 8:00 a.m. - 4:30 p.m.
• Days of Work: Monday - Friday
• Travel Required: Yes
• Salary Range: $35.43 - $52.53 / hourly; $73,977 - $109,682 / annually
• Classified Status: Classified
• Bargaining Unit/Union: 214 - MN Assoc of Professional Empl/MAPE
• FLSA Status: Exempt - Administrative
• Designated in Connect 700 Program for Applicants with Disabilities: Yes
  
  

The Department of Human Services (DHS) is unable to provide sponsorship for work visas. Applicants must be eligible to work in the United States at the start of employment. DHS does not participate in E-Verify.

The work you'll do is more than just a job.

At the State of Minnesota, employees play a critical role in developing policies, providing essential services, and working to improve the well-being and quality of life for all Minnesotans. The State of Minnesota is committed to equity and inclusion, and invests in employees by providing benefits, support resources, and training and development opportunities.

• Telework (within Minnesota or neighboring States) and flexible hours options are available.
• Up to 10% travel to contracted Managed Care Organizations (MCOs) and required meetings.
  
  

Minnesota’s contracted Managed Care Organizations (MCOs), responsible for administering Medical Assistance (MA) for over 87% of the state's enrolled recipients, are federally mandated and contractually obligated by the State of Minnesota to conduct a variety of program integrity activities. This includes establishing Special Investigations Units (SIUs) tasked with preventing, detecting, and addressing fraud, waste, abuse, and noncompliance resulting in improper payments.

The State of Minnesota, through its Office of Inspector General (OIG), ensures that MCOs and their subcontractors implement and maintain robust integrity programs designed to prevent and detect fraud, waste, and abuse within the Medical Assistance (MA) program.

This role coordinates and oversees the program integrity activities and anti-fraud efforts of Department of Human Services (DHS)-contracted MCOs. Key responsibilities include planning, developing, and implementing goals and strategies, and assessing the performance of MCOs. The position also involves providing consultation, direction, and oversight to MCO contractors from a program integrity perspective.

Additionally, this role offers technical consultation on legislative, policy, and compliance issues to the Program Integrity Oversight Division (PIO). Oversight extends to the program integrity-related work of MCO delegated entities, including claims administrators and benefit administrators (Pharmacy, Dental, and Chiropractic), as well as other subcontractors engaged by the MCOs in Minnesota Health Care Programs (MHCP).

Minimum Qualifications

• To facilitate proper crediting, please ensure that your resume clearly describes your experience in the areas listed and indicates the beginning and ending month and year for each job held.**
  
  

Three (3) years of experience designing and coordinating program integrity initiatives and conducting oversight of Managed Care Organizations (MCOs) operations.

Experience must demonstrate the following:

• Conduct or lead MCO program integrity-related reviews and/or audits.
• Knowledge of the principles and practices of Medicaid program integrity and anti-fraud program components including detection, investigation, resolution and reporting.
• Format, analyze, and prepare computer generated reports.
• Analyze health care benefits-related data, provider documentation, financial records, and/or other program integrity-related data and identify discrepancies.
  
  

Preferred Qualifications

• Advanced knowledge of legislation, rule, contractual and managerial approaches to Managed Medicaid oversight sufficient to advise the state and keep its Medicaid program in compliance.
• Extensive knowledge of Federal oversight authority of the Medicaid program, as it relates to both fee for service (FFS) and Managed Care Organization (MCO), and an understanding of the State's role in administering Medicaid to assure compliance with federal requirements.
• Thorough knowledge of benefit adjudication systems and sub-systems such as Minnesota Medicaid Information System (MMIS) and Data Warehouse used by Department of Human Services (DHS), as well as the various commercial and proprietary systems used by the MCOs.
• Working knowledge of data mining and detection systems used to detect provider fraud, waste, and abuse.
• Working knowledge of state requirements and procedures sufficient to draft and propose contract provisions.
• Working knowledge of basic computer applications such as Microsoft Word, Excel, and Adobe Acrobat, as well as more advanced applications such as data mining, data visualization, project management, flow-charting and presentation.
• Advanced knowledge of data and systems used in benefits adjudication, fraud detection, investigation case management, and program integrity environments.
• Respond and adapt to changes in priorities, operations, policies, procedures, laws, and rules within a minimal timeframe.
• Variety of experiences working effectively with others from different backgrounds and cultures.
  
  

Additional Requirements

To facilitate proper crediting, please ensure that your resume clearly describes your experience in the areas listed and indicates the beginning and ending month and year for each job held.

REFERENCE/BACKGROUND CHECKS - The Department of Human Services will conduct reference checks to verify job-related credentials and criminal background check prior to appointment.

How To Apply

Select “Apply for Job” at the top of this page. If you have questions about applying for jobs, contact the Careers Help Desk at 651-259-3637 or email careers@state.mn.us. For additional information about the application process, go to http://www.mn.gov/careers.

Contact

If you have questions about the position, contact David Cammack at david.cammack@state.mn.us.

To receive consideration as a Connect 700 Program applicant, apply online, email the Job ID#, the Working Title and your valid Proof of Eligibility Certificate by the closing date to Carolyn Rice at carolyn.rice@state.mn.us.

If you are an individual with a disability and need an ADA accommodation for an interview, you may contact the Department of Human Services’ ADA Coordinator at 651-431-4945 or DEPARTMENT OF HUMAN SERVICES_ADA@state.mn.us for assistance.

About Human Services Dept

WE MAKE A DIFFERENCE! The Minnesota Department of Human Services impacts the lives of 1.7 million people every year, helping them meet their basic needs so they can achieve their highest potential.

Working together to improve the state we love.

What do Minnesota's State employees have in common?

• A sense of purpose in their work
• Connection with their coworkers and communities
• Opportunities for personal and professional growth
  
  

Benefits

As an employee, you'll have access to one of the most affordable health insurance plans in Minnesota, along with other benefits to help you and your family be well.

Your benefits may include:

• Paid vacation and sick leave
• 12 paid holidays each year
• Low-cost medical, dental, vision, and prescription drug plans
• Fertility care, including IVF
• Diabetes care
• Dental and orthodontic care for adults and children
• 6 weeks paid leave for parents of newborn or newly adopted children
• Pension plan that provides income when you retire (after working at least three years)
• Employer paid life insurance to provide support for your family in the event of death
• Short-term and long-term disability insurance that can provide income if you are unable to work due to illness or injury
• Tax-free expense accounts for health, dental, and dependent care
• Resources that provide support and promote physical, emotional, social, and financial well-being
  
  

Support to help you reach your career goals:

• Training, classes, and professional development
• Tuition reimbursement
• Federal Public Service Loan Forgiveness Program (Some positions may qualify for the Public Service Loan Forgiveness Program. For more information, visit the Federal Student Aid website at studentaid.gov)
  
  

Employee Assistance Program (EAP) for work/life support:

• A voluntary confidential program that helps employees and their families with life challenges that may impact overall health, personal well-being, or job performance
• Common sources of stress can be addressed through the EAP: mental health, relationship challenges (personal and work), grief and loss, finances, and legal issues
• Daily Living/Convenience Services: Chore services, home repair, trip planning, child/elder care
  
  

Programs, resources and benefits eligibility varies based on type of employment, agency, funding availability, union/collective bargaining agreement, location, and length of service with the State of Minnesota.

EQUAL OPPORTUNITY EMPLOYERS

Minnesota state agencies are equal opportunity, affirmative action, and veteran-friendly employers. State agencies are committed to creating a workforce that reflects the diversity of the state and strongly encourages persons of color and Indigenous communities, members of the LGBTQIA2S community, individuals with disabilities, women, and veterans to apply. The varied experiences and perspectives of employees strengthen the work we do together and our ability to best serve Minnesotans.

All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, national origin, sex (including pregnancy, childbirth, and disabilities related to pregnancy or childbirth), gender identity, gender expression, marital status, familial status, age, sexual orientation, status regarding public assistance, disability, veteran status or activity in a local Human Rights Commission or any other characteristic protected by law.

Applicants With Disabilities

Minnesota state agencies make reasonable accommodations to their employees and applicants with disabilities. If you have a disability and need assistance in searching or applying for jobs with the State of Minnesota, call the Careers Help Desk at 651-259-3637 or email careers@state.mn.us and let us know the support you need.