Purpose of Position/Summary:
The Office of Medicaid Policy and Planning (OMPP) is a division within the Family and Social Services Administration (FSSA), which receives around 13 percent of the state's budget to ensure vital health care coverage to approximately 1 in 5 Hoosiers. OMPP strives to build programs and processes that enable Hoosiers to live in fully engaged communities and reach their greatest emotional, mental and physical well-being. Our mission is to support individual and community well-being with effective and efficient programs, remarkable collaborations, measurable impact on individuals and communities, and an energized staff that is fully engaged with this mission
The Manager of Medical Frailty supports OMPP in overseeing the complex classification of Healthy Indiana Plan beneficiaries who qualify for exemptions from Medicaid community engagement requirements. This position bridges clinical teams, IT systems, and legal departments to verify medical frailty using claims data, provider certifications, and health screener. The position provides statewide clinical oversight of the medically frail identification and verification process, including review of Managed Care Organization (MCO) determinations, management of the MARA (Milliman Advanced Risk Adjusters) tool, and coordination with the Division of Family Resources (DFR), Gainwell, and other partners to ensure compliance with federal and state requirements.
This roe ensures that medically frail determinations are individualized, evidence-based, and clinically justified, rather than automatically assigned based on diagnosis alone. The Manager of Medical Frailty will conduct clinical reviews, perform retrospective audits, validate MCO submissions, and ensure that members who qualify for medically frail protections receive appropriate benefits and coverage pathways.
The ideal candidate is a Registered Nurse (RN) with experience in Medicaid, managed care, clinical assessment, disability determination, utilization management, or care management. Strong analytical skills, clinical judgment, and familiarity with federal medically frail criteria are essential.
Essential Duties/Responsibilities:
* Statewide Medical Frailty Oversight
* Oversee the medical frail identification and verification process across all Indiana Medicaid programs.
* Review and validate MCO medically frail determinations for accuracy, completeness, and compliance.
* Ensure determinations reflect clinical judgment, not automatic assignment based solely on diagnosis (e.g. HIV, SUD, chronic conditions).
* Provide final clinical determinations for complex or borderline cases.
* MARA Tool Management
* Serve as the program lead for the MARA risk-adjustment tool as it relates to medically frail identification.
* Interpret MARA outputs and integrate them into the medically frail review workflow.
* Collaborate with actuarial and analytics teams to refine MARA parameters and ensure alignment with policy intent.
* Cross-Agency Coordination
* Work closely with DFR to ensure accurate eligibility pathways for medically frail members.
* Coordinate with Gainwell on systems configuration, data accuracy, and backend processing.
* Provide clinical consultation to internal teams regarding medically frail criteria, documentation standards, and case resolution.
* Audit & Compliance
* Conduct retrospective audits of MCO determinations to ensure compliance with federal and state medically frail requirements.
* Identify patterns of over- and under-designation and implement corrective action plans.
* Ensure the state remains aligned with federal Centers for Medicare & Medicaid Services (CMS) guidelines regarding the “significantly impairs” standard and 12-month look-back periods.
* Clinical Review & Determination
* Perform clinical assessments of member documentation to determine whether functional or behavioral health needs meet medically frail criteria.
* Apply federal definitions, including serious and complex medical conditions, functional impairments, and chronic substance use disorders.
* Document clinical rational or determinations and communicate decisions to MCOs and internal partners.
* Data Analysis & Reporting
* Analyze medically frail trends, disparities, and program impacts.
* Collaborate with FSSA Data & Analytics to develop dashboards and reports to support oversight and policy decisions.
* Monitor MCO performance and identify opportunities for improvement.
* Other Duties as Assigned
Job Requirements:
You must meet the following requirements to be considered for employment:
* Registered Nurse (RN) license required (Indiana or compact state)-active and in good standing.
* Bachelor’s degree in nursing required.
* Strong knowledge of Medicaid programs, eligibility pathways, and medically frail criteria.
* Experience with clinical assessment, disability determination, care management, or utilization review.
* Ability to interpret federal and state reuglations and apply them to complex clinical scenarios.
Supervisory Responsibilities/Direct Reports:
This role may supervise staff supporting medically frail operations, audits, or clinical review functions.
Difficulty of Work:
Work requires advanced clinical judgment, interpretation of complex regulations, and the ability to apply nuanced criteria to individual cases. Work is both strategic and detail-oriented, requiring autonomy, accuracy, and sound decision-making.
Personal Work Relationships:
Must work effectively with OMPP leadership, DFR, Gainwell, MCOs, actuarial teams, analytics teams, and external partners. Must be able to represent OMPP’s clinical and policy positions professionally and accurately.
Physical Effort:
No unusual physical effort is required. May be required to carry or lift up to 10 lbs. occasionally. Will be required to type/use a computer for extended periods of time. Some meetings are day-long and require continuous attendance offsite.
Working Conditions:
Standard office environment when present in office. Occasional travel may be required with some overnight stays possible, dependent on season/time of year. The nature of this position may occasionally require commitments of time in excess of the standard workday.