**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 (https://mn.gov/mmb/careers/diverse-workforce/people-with-disabilities/connect700/) : 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 (https://dhs.intranet.mn.gov/buildings-facilities/hybrid-telework/telework/index.jsp) **_(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. AN EQUAL OPPORTUNITY EMPLOYER Minnesota State Colleges and Universities is an Equal Opportunity employer/educator committed to the principles of diversity. We prohibit discrimination against qualified individuals based on their race, sex, color, creed, religion, age, national origin, disability, protected veteran status, marital status, status with regard to public assistance, sexual orientation, gender identity, gender expression, or membership in a local commission as defined by law. As an affirmative action employer, we actively seek and encourage applications from women, minorities, persons with disabilities, and individuals with protected veteran status. Reasonable accommodations will be made to all qualified applicants with disabilities. If you are an individual with a disability who needs assistance or cannot access the online job application system, please contact the job information line at 651-259-3637 or email careers@state.mn.us . Please indicate what assistance is needed.