Medicaid Payment Integrity Lead Analyst - Human Services Program Representative 1

Working Title: Medicaid Payment Integrity Lead Analyst

Job Class: Human Services Program Representative 1

Agency: Human Services Dept

• Job ID : 98392

• 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 : 11/12/2026

• Closing Date : 11/18/2026

• Hiring Agency/Seniority Unit : Human Services Dept / MAPE DHS Central Office

• Division/Unit : DHS-Central Office / BHA Program Integrity

• Work Shift/Work Hours : Day Shift / 8:00am to 4:30pm

• Days of Work : Monday - Friday

• Travel Required : Yes, (20% for meetings)

• Salary Range: $29.76 - $43.69 / hourly; $62,138 - $91,224 / annually

• Classified Status : Classified

• Bargaining Unit/Union : 214 - MN Assoc of Professional Empl/MAPE

• FLSA Status : Nonexempt

• Designated in Connect 700 Program for Applicants with Disabilities (https://mn.gov/mmb/careers/diverse-workforce/people-with-disabilities/connect700/) : Yes

**This posting will be used to fill five (5) identical openings **

The Department of Human Services 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.

This position is eligible for telework (https://mn.gov/mmb-stat/policies/1422-telework.pdf) for applicants who reside in Minnesota or in a bordering state, with supervisory approval and satisfactory performance. If you live in a state bordering Minnesota, you must live within 50 miles or less from the primary work location to be eligible for telework.

Flexible work hours may be permitted with supervisor approval.

This position exists to serve as a principal staff specialist and subject matter expert in Medicaid program integrity for behavioral health services administered by the Behavioral Health Administration (BHA). The position conducts complex clinical and policy review of Medicaid claims through prepayment review and Centers for Medicare & Medicaid Services (CMS)–directed focused claims review of questionable claims across the full behavioral health continuum: substance use disorder (SUD) services, adult and children's mental health services, and integrated and co-occurring services. The incumbent interprets and applies federal and state statute, rule, the Medicaid State Plan, and program policy to independently determine whether services are allowable, medically necessary, clinically appropriate, and properly documented, and resolves the complex and ambiguous cases that fall outside established review procedures.

As BHA expands program integrity review to additional service areas, this position develops, applies, and modifies the review criteria, protocols, and policy guidance that govern that work; analyzes claims and review data to identify provider and systemic risk; identifies systemic program vulnerabilities to inform BHA substantive policy teams; translates statutory requirements into operational audit rubrics; and serves as a technical review resource to BHA leadership, review specialists, and agency partners. The position protects the integrity of Minnesota's Medicaid program, ensures appropriate use of public funds, and preserves access to medically necessary behavioral health care for Minnesotans who rely on it.

Some responsibilities include, but are not limited to:

• Conduct complex clinical and policy review of Medicaid behavioral health claims through prepayment review and CMS-directed focused claims review, independently determining whether services are allowable, medically necessary, and compliant with federal and state requirements, and resolving the complex, ambiguous, and precedent-setting cases that exceed established review procedures.

• Interpret regulatory requirements, develop and modify operational review protocols, and establish audit criteria for BHA behavioral health services to ensure determinations are legally defensible and consistent.

• Plan, develop, and implement the expansion of Medicaid program integrity review to additional BHA service areas, serving as lead analyst for an assigned service portfolio and coordinating with BHA policy teams, Healthcare Administration (HCA), and Office of Inspector General (OIG).

• Analyze claims, review, and provider data to identify patterns of improper billing, provider risk, and systemic program vulnerabilities, and use findings to target review activity and inform policy and program decisions.

• Serve as a subject matter expert, policy resource, and technical consultant on behavioral health program integrity, providing specialized case consultation, clinical calibration, training, and technical assistance to review staff, internal partners, and providers.

• Maintain complete and accurate program integrity records and documentation to support audits, appeals, CMS reporting, and program oversight.

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.

Two (2) years of providing advisory-level work experience working with Medicaid-enrolled behavioral health providers and their billing and clinical staff regarding documentation requests, determinations, and technical assistance for human services program that demonstrate the following:

• Experience with Minnesota's behavioral health service delivery system across SUD, mental health, and integrated services, including service standards, provider qualifications, and documentation requirements under Minnesota Statutes chapters 245G, 245I, 254B, and 256B and related rules.

• Practical understanding of Medicaid program integrity methods, including prepayment review, focused claims review, improper payment identification, risk-based targeting, and fraud, waste, and abuse indicators.

• Experience with Medicaid program requirements, including the Medicaid State Plan, the MHCP Provider Manual, medical necessity and coverage policy, and federal program integrity requirements (including 42 CFR Parts 455 and 456).

• Practical understanding of behavioral health coding and billing, including CPT and HCPCS codes, modifiers, and claims adjudication.

• Working knowledge of data privacy regulations: Minnesota Government Data Practices Act, HIPAA, and 42 CFR Part 2.

*Bachelor’s degree or higher in human services, counseling, social work, or another related fields can substitute for one (1) year of required work experience.

Preferred Qualifications

• Variety of experiences working effectively with others from different backgrounds and cultures; including but not limited to Minnesota Tribal communities.

• Strong human relations and communication skills; communicate clearly and professionally both verbally and in writing; respond openly to requests and concerns for internal and external stakeholders.

• Understanding of ASAM Criteria and multidimensional assessment, and diagnostic and level-of-care standards for mental health and co-occurring conditions.

• Policy analysis and the state legislative and rulemaking processes.

Additional Requirements

• MinnesotaDepartmentofHumanServices(DHS) will conduct a criminalbackgroundcheckonallfinalistsforthisposition.Finalistsmustpassthe DHS backgroundcheck.

• Employee reference checks will be conducted on all finalists. This may include a review of documentation related to jobperformance.It alsoincludescontact withtheapplicant'sformer employer(s).

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 [email protected] . Please indicate what assistance is needed.