Medicaid Program Integrity Review Specialist - Human Services Program Specialist 1

Location: St. Paul
Telework eligible: Yes (applicants must reside in Minnesota or a bordering state within 50 miles of the primary work location)
Full-time, temporary positions (18 months, possibility of extension)

About the role

Join a new review team examining behavioral health services billed to Minnesota’s Medicaid program. As a Medicaid Program Integrity Review Specialist, you will review clinical records and claims to ensure services meet program requirements and public funds are used appropriately. The services under review include Adult Rehabilitative Mental Health Services (ARMHS), Intensive Residential Treatment Services (IRTS), Peer Services, and Assertive Community Treatment (ACT). You’ll collaborate with teammates, supervisors, and DHS policy experts in a supportive environment.

Responsibilities

• Review clinical documentation—including records for prepayment review, focused claims review, and provider recertification—to verify completeness, accuracy, and compliance with state and federal requirements.
• Apply clinical knowledge and Medicaid policy guidelines to make preliminary determinations about medical appropriateness, documentation support for claims, and provider recertification standards.
• Collaborate with policy experts and program specialists to clarify requirements, resolve complex cases, and ensure consistent application of review standards.
• Maintain accurate records of review activities to support audits, provider communications, and program oversight.
• Participate in ongoing training and quality improvement activities to stay current on behavioral health services, documentation standards, and review procedures.

Requirements

Applicants must meet one of the following experience pathways:

• One year of advanced or strategic-level work experience in a human services program involving Medicaid providers, plus the required applicant experience listed below.
• Three years of advanced technical or paraprofessional experience in a human services program involving Medicaid providers, plus the required applicant experience listed below.
• A bachelor’s degree or higher in human services, social work, or a closely related field, plus two years of advanced technical or paraprofessional experience in a human services program involving Medicaid providers, plus the required applicant experience listed below.

Required applicant experience must demonstrate:

• Working understanding of behavioral health conditions and treatment approaches.
• Experience applying Medicaid program rules and medical necessity concepts.
• Practical knowledge of clinical documentation standards and behavioral health service delivery systems.
• Familiarity with HIPAA, Minnesota data practices law, and confidentiality requirements for handling sensitive health information.
• Experience with or awareness of program integrity review methods (e.g., prepayment review, focused claims review, provider recertification), audit processes, fraud prevention, and Medicaid program integrity standards.
• Basic understanding of healthcare coding and billing as it applies to behavioral health services.
• Proficiency using computers for data entry and electronic documentation systems.

Preferred Qualifications

• Strong analytical and critical thinking skills to evaluate clinical documentation and identify issues.
• Excellent attention to detail, especially when reviewing records for discrepancies or missing information.
• Clear written communication skills for documenting findings professionally and organizedly.
• Ability to manage multiple reviews simultaneously and prioritize effectively.
• Collaborative and interpersonal skills to work with policy experts, providers, and team members from diverse backgrounds.
• Ability to research, interpret, and apply policy updates and clinical guidelines.
• Experience with Medicaid claims platforms, electronic health record (EHR) systems, or reporting tools.

Additional Requirements

• All finalists must pass a Minnesota Department of Human Services (DHS) criminal background check.
• Employee reference checks will be conducted, including a review of job performance documentation and contact with former employers.

Pay

$24.40 - $35.30/hour ($50,947 - $73,706/year)

Schedule

Day shift: 8:00 AM – 4:30 PM, Monday – Friday

Benefits

• Paid vacation and sick leave.
• 12 paid holidays per year.
• Low-cost medical, dental, vision, and prescription drug plans.
• Fertility care, including IVF, and diabetes care.
• Dental and orthodontic care for adults and children.
• 6 weeks of paid leave for parents of newborn or newly adopted children.
• Pension plan providing retirement income (after three years of service).
• Employer-paid life insurance.
• Short-term and long-term disability insurance.
• Tax-free expense accounts for health, dental, and dependent care.
• Resources supporting physical, emotional, social, and financial well-being.
• Career development support, including training, classes, professional development, and tuition reimbursement.
• Federal Public Service Loan Forgiveness Program eligibility (for qualifying positions).
• Employee Assistance Program (EAP) for work/life support, including mental health, relationship challenges, grief, finances, and legal issues.
• Daily living/convenience services, such as chore services, home repair, trip planning, and child/elder care.

Benefits eligibility varies based on employment type, agency, funding, union agreements, location, and length of service.