RFP 27-88343 - Att K4 - Exhibit 1 Indiana PathWays for Aging - Statement of Work [Add. 1].docx

EXHIBIT 1

STATEMENT OF WORK - INDIANA PATHWAYS FOR AGING

TABLE OF CONTENTS

I. EXECUTIVE SUMMARY

This Statement of Work is part of a Contract to provide statewide, risk-based managed care services to Medicaid beneficiaries enrolled in the State of Indiana’s PathWays for Aging (PathWays) program. The State is looking to contract on a statewide basis with proven managed care organizations (MCOs) with a demonstrated capacity to coordinate and provide member-driven, accessible, equitable and high-quality services to eligible Medicaid members for medical, behavioral, and long-term services and supports.

Because PathWays is financed in part by federal Medicaid funds, the Contractor must meet all applicable requirements of Medicaid managed care organizations pursuant to Section 1903(m) and 1932 of the Social Security Act, as well as the implementing regulations set forth in 42 CFR 438, which defines requirements for Medicaid managed care programs. The Contractor must also ensure that its network providers, including out-of-state providers, enroll in the Indiana Health Coverage Programs (IHCP) before they begin providing health care services to members. Further information about IHCP provider enrollment is located at:

https://www.in.gov/medicaid/providers/provider-enrollment/become-a-provider/

Unless otherwise indicated, the requirements set forth in this Statement of Work apply to the Contractor’s responsibilities under the PathWays program. Definitions for terms cited throughout the Statement of Work are listed in Exhibit 5 Contract Definitions unless otherwise specified.

II. BACKGROUND AND CURRENT STATE

Background

The Indiana Family and Social Services Administration (FSSA) Office of Medicaid Policy and Planning (OMPP) maintains the five (5) Medicaid programs described below. For purposes of this Statement of Work, the term “FSSA” shall refer to the agency and its divisions, including, but not limited to OMPP.

As the State continues to evaluate and design Medicaid benefits, the State reserves the right to add additional populations not currently outlined in this Contract into its managed care programs.

Hoosier Healthwise

Hoosier Healthwise is a Medicaid program that helps approximately five hundred and eighty-nine thousand (589,000) Hoosiers. The program’s aim is to provide comprehensive health care coverage for children up to age nineteen (19) and pregnant individuals.

The Contractor must perform the administrative functions of a typical insurer, as well as address the unique challenges of low-income children and families, including managing and integrating care along the continuum of health care services.

Healthy Indiana Plan

FSSA has maintained the Healthy Indiana Plan program since 2008. Healthy Indiana Plan is one of the Medicaid programs that helps over four hundred and eighty-seven thousand (487,000) Hoosiers. Healthy Indiana Plan aims to provide comprehensive health care coverage for low-income adults aged nineteen to sixty-four (19 to 64) that may not be otherwise eligible for Medicare or Medicaid and most pregnant women covered by Medicaid.

The State of Indiana intends to implement modifications to the Healthy Indiana Plan (HIP) program whereby all non‑expansion adult members, including pregnant women, will be transitioned to the Hoosier Healthwise Medicaid Managed Care program. Following these changes, the Healthy Indiana Plan will be designated exclusively for Medicaid expansion adults. The State will undertake all necessary steps to effectuate this transition in accordance with Federal and State requirements. The Healthy Indiana Plan and Hoosier Healthwise Statement of Work documents will be updated to reflect these changes prior to implementation of the program change.

The Healthy Indiana Plan program seeks not only to provide health coverage to an uninsured population, but to improve health, promote prevention and encourage healthy lifestyles.

Hoosier Care Connect

FSSA has maintained the Hoosier Care Connect program since 2015, and it currently serves approximately eighty thousand (80,000) Hoosiers. Hoosier Care Connect is a coordinated care program for Indiana’s Medicaid members under the age of sixty (60) meeting the following criteria:

· Blind individual,

· Individual with a disability,

· Wards, foster children, former foster children and children receiving adoption assistance,

· Are not eligible for Medicare, or

· Are not on a 1915(c) Medicaid waiver.

Through the Hoosier Care Connect program, FSSA seeks to improve the quality of care and health outcomes for the identified population. This includes improved clinical and functional status, enhanced quality of life, improved member safety, and enhanced member autonomy and adherence to treatment plans.

PathWays for Aging

FSSA has managed the PathWays program since inception in 2024. PathWays serves approximately one hundred and fifteen thousand (115,000[footnoteRef:2]) Hoosiers. Indiana’s PathWays program is a statewide coordinated care program for Indiana’s Medicaid members who are sixty (60) years of age and older and are eligible for Medicaid on the basis of age, blindness, or disability and have limited income and resources. All individuals who are sixty (60) years of age or older in the target eligibility categories will be included unless they meet an exclusion, as specified in Exhibit 3 Program Description and Covered Benefits. Members include members who have a full Medicare benefit and those who are receiving long-term services and supports (LTSS) in a home or community-based setting. LTSS includes Home and Community Based Services (HCBS) which are intended to support individuals who have functional limitations and/or chronic illnesses that have the primary purpose of supporting the ability of the member to live or work in the setting of their choice. HCBS services include, but are not limited to, in-home personal care, adult day centers, assisted living, and caregiver support. [2: The enrollment figures provided in this Statement of Work are current figures only. Enrollment in the programs may increase or decrease in the future based upon federal policies, program priorities, available funding, etc.]

In developing PathWays, FSSA seeks to achieve the following:

· Ensure more Hoosiers can choose to age at home and simplify access to HCBS

· Appropriately divert individuals from long-term nursing facility stays in accordance with a person-centered approach through high-quality care coordination, coordinated care across the delivery system and care continuum, including across Medicaid and Medicare for dually eligible members, and taking into account physical health, behavioral health, and social services

Fee-for-Service

Fee-for-Service (FFS) Medicaid provides full health coverage to individuals eligible for Medicaid and are an excluded population from managed care enrollment, such as individuals receiving intellectual and developmental disability services through the Division of Disability, Aging, and Rehabilitation Services (DDARS); American Indian and Alaskan Natives; individuals under the age of sixty (60) who are Medicaid and Medicare (dual) eligible; and individuals residing in institutional settings. FFS Medicaid serves approximately two hundred and forty thousand (240,000) Medicaid eligible individuals. FFS Medicaid benefits include all services that are covered under Package A-Standard Plan.

III. SCOPE OF WORK

a. OBJECTIVES OF ENGAGEMENT

MCO Investment in Quality

Across all Indiana coordinated programs, FSSA has the triple aim of:

· Make Indiana Healthy Again

· Partner with plans dedicated to the State of Indiana

· Ensure fiscal integrity and responsibility of Medicaid programs

The Contractor must ensure compliance to all program requirements and guidance issued by the State including, but not limited to, each program’s Policies and Procedures Manual as updated and amended periodically.

The State expects Contractors to align their resources toward achieving improvement in the goal areas. Examples include:

· Member and provider outreach and education efforts supporting the goals

· Enhanced Benefits offered by the Contractor should be intentionally selected to support quality goals

· Member and provider incentives and Value-Based Purchasing arrangements designed to support the goals

Administrative Requirements

The Contractor must comply with all applicable Federal and State laws, regulations and executive orders.

State Licensure

Prior to the Contract effective date, and as verified in the readiness review, the Contractor must be an Indiana-licensed health maintenance organization (HMO).

The Contractor and all subcontractors must use clinicians licensed by Indiana and follow all requirements contained within the Contract (e.g., PA/UM criteria; claims processing; encounter data submission; etc.), regardless of geographic location. As required by IC 12-15, subcontractors must verify that providers hold a current unrestricted Indiana license even if the Contractor is based in another state.

National Committee for Quality Assurance (NCQA) Accreditation

As required by IC 12-15-12-21, the Contractor must be an accredited Health Plan by the National Committee for Quality Assurance (NCQA) with the LTSS Distinction on or before the Contract start date. In the event the Contractor is not accredited on or before the Contract start date, the Contractor must begin the accreditation process and obtain accreditation at the earliest time that the NCQA allows. When accreditation standards conflict with the standards set forth in the Contract, the Contract prevails, unless the accreditation standard is more stringent.

If the Contractor is accredited as of the start date of the agreement, the Contractor must maintain accreditation throughout the term of this agreement. If the Contractor is not accredited as of the start date of this agreement, the Contractor must obtain their Health Plan accreditation and the LTSS Distinction for Health Plans no later than the end of the second full calendar year of operation and must maintain accreditation for the term of this agreement.

The Contractor must submit to FSSA the final Accreditation Report for each accreditation cycle within ten (10) business days of receipt of the report. The Contractor must submit to FSSA updates of accreditation status, based on annual HEDIS scores, within ten (10) days of receipt.

Per 42 CFR 438.332(b), the Contractor must authorize NCQA to provide the State a copy of its most recent accreditation review including: its accreditation status, survey type, and level (as applicable); recommended actions or improvements, corrective action plans, and summaries of findings; and the expiration date of the accreditation. As required by 42 CFR 438.332(c), FSSA shall publish on its website the accreditation status of each Contractor.

Administrative and Organizational Structure

The Contractor shall maintain an administrative and organizational structure that supports effective and efficient delivery of integrated services to members. The organizational structure shall demonstrate a coordinated approach to managing the delivery of health care services to its PathWays members. The Contractor’s organizational structure must support the collection and integration of data from every aspect of its delivery system and its internal functional units to accurately report the Contractor’s performance. The Contractor must also have policies and procedures in place that support the integration of financial and performance data and comply with all applicable federal and state requirements.

Prior to the contract effective date, FSSA will support the Contractor in developing its internal operations to meet the requirements of the contract (i.e., data submission, data transmissions, reporting formats, etc.).

The Contractor must have in place sufficient administrative and clinical staff and organizational components to comply with all PathWays program requirements and standards. The Contractor must manage the functional linkage of the following major operational areas:

· Administrative and fiscal management

· Member services

· Provider enrollment and services

· Case Management

· Member information, education, and outreach

· Network development and management

· Quality management and improvement

· Utilization management

· Clinical assessment, prevention and wellness program(s), care coordination, complex case management, and service coordination

· Special investigations and waste, fraud, and abuse detection

· Behavioral and physical health

· Information systems

· Performance data reporting and encounter claims submission

· Claims payments

· Grievances and appeals

· Vendor management

· Medicare and Medicaid coordination

The Contractor’s organizational and operational structure must be capable of fulfilling all contract requirements. Furthermore, the Contractor and Contractor’s operations must be located inside of the United States. Per 42 CFR 438.602(i), no claims paid by the Contractor to a network provider, out-of-network provider, subcontractor or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates per.

Administrative Office

The Contractor must establish and maintain a business office or work site within five (5) miles of the Indiana Government Center, Indianapolis, Indiana where it is expected that, at minimum, the executive leadership team, and preferably all key staff will perform the majority of their duties, as well as ensuring a significant portion of the Contractor’s operations are based there. The Contractor must ensure the location of operational functions outside of Indiana does not compromise the delivery of integrated services and a seamless experience for members and providers. All staff working on the State of Indiana’s business must be available to the State at the Indiana Government Center or at the Contractor’s Indianapolis, Indiana business office at the discretion of the State.

The Contractor must provide sufficient on-site meeting space that is private and allows the state to perform on-site reviews, audits, or other oversight activities.

The Contractor must be responsible for all costs related to securing and maintaining the facility for interim start-up support and the subsequent operational facility.

Staffing

The Contractor must have in place qualified administrative and clinical staff as well as sufficient organizational components to comply with all program requirements and standards. The Contractor must maintain a high level of Contract performance and data reporting capabilities regardless of staff vacancies or turnover. The Contractor must have an effective method to address and minimize staff turnover (e.g., cross training, use of temporary staff or consultants, etc.) as well as processes to solicit staff feedback to improve the work environment. Staff designated for this specific Medicaid program must have experience with long-term services and supports, HCBS, and older adults who are aged, blind, or disabled.

All key staff must reside in Indiana, and all other staff must perform the majority of their work within Indiana unless explicitly exempted by the Contract. It is expected that key staff must carry out the majority of their daily responsibilities from the Indianapolis location. The Contractor must provide documentation upon request to verify compliance with these requirements.

The Contractor must ensure the location of any staff functions outside of Indiana does not compromise the delivery of integrated services and a seamless experience for members and providers. Additionally, the Contractor will be responsible for ensuring all staff functions conducted outside of the state are readily reportable to FSSA at all times to ensure such location does not hinder the State’s ability to monitor the Contractor’s performance and compliance with Contract requirements. The Contractor must receive State approval for functions to be conducted outside of Indiana and identify how out-of-state staff will be supervised to ensure compliance with Contract requirements. Indiana-based staff must maintain a full understanding of the operations conducted out-of-state, and must be prepared to discuss these operations with FSSA upon request, including during unannounced FSSA site visits.

The Contractor must have position descriptions for the positions discussed in this section that include the responsibilities and qualifications of the position such as, but not limited to: education (e.g., high school, college degree or graduate degree), professional credentials (e.g., licensure or certifications), work experience, membership in professional or community associations, etc.

The State of Indiana maintains the right and authority to approve or deny all Contractor staff, including subcontractor and vendor staff from working on the State’s business. Individuals the State denies must have their access to State of Indiana information terminated within one (1) hour of notification to the Contractor.

The Contractor must ensure qualified staff in each major operational area has appropriate skills, knowledge, and experience with the unique aspects of geriatrics, LTSS populations and services, Home and Community Based Services (HCBS) coordination, as well as the coordination of Medicare and Medicaid. Prior LTSS experience or experience serving the program population across staff is preferred. Staff will be culturally competent.

Key Staff

The Contractor must employ the key staff members listed below. The Contractor must employ qualified staff to achieve compliance with contractual requirements and performance metrics.

The Contractor must maintain a backup personnel plan, including a discussion of the staffing contingency plan for (i) the process for replacement of personnel in the event of a loss of key staff or others before or after signing a Contract; (ii) allocation of additional resources to the Contract in the event of an inability to meet a performance standard; (iii) replacement of staff with key qualifications and experience and new staff with similar qualifications and experience; (iv) the time frame necessary for obtaining replacements; (v) the method of bringing replacement or additions up to date regarding the Contract; and (vi) how the Contractor will keep the State aware of the process for replacing key staff or others starting from the initial loss of staff, through the replacement process, and finishing with State approval before the finalization of a replacement.

Per 42 CFR 455.104(b)(4), the Contractor must submit the name, address, date of birth, and SSN of any managing employee of the Contractor. A managing employee is defined as a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency. The plan president/CEO is the final decision maker on day-to-day operations of an organization. The Contractor must submit the federally required personal information of their President/CEO upon the State’s request.

The Contractor must submit to FSSA for approval all initial and replacement key staff prior to their assignment to the PathWays project. With reasonable notice and a statement of the reasons for the request, FSSA shall have the right to require that the Contractor remove any individual (whether or not key staff) from assignment to the project. If the Contractor desires to change the individual in a key staff position at any point in the Contract, the Contractor must submit the request and the resume(s) of the candidate(s) to FSSA for approval prior to making the change.

Except in the circumstance of the unforeseeable loss of a key staff member’s services, the Contractor must provide written notification to FSSA of anticipated vacancies of key staff within five (5) business days of receiving the key staff person’s notice to terminate employment or five (5) business days before the vacancy occurs, whichever occurs first. At that time, the Contractor must present FSSA with an interim plan to cover the responsibilities created by the key staff vacancy. Likewise, the Contractor must notify FSSA in writing within five (5) business days after a candidate’s acceptance to fill a key staff position or five (5) business days prior to the candidate’s start date, whichever occurs first. A candidate cannot officially start their role until FSSA has approved them as a replacement.

In addition to attendance at vendor meetings, all key staff must be accessible to FSSA and its other program subcontractors via telephone, voicemail, and electronic mail systems. As part of reporting, the Contractor must submit to FSSA an updated organizational chart including e-mail addresses and phone numbers for key staff. An updated organizational chart must be provided within ten (10) business days of a key staff member being replaced.

During readiness review, the Contractor must submit a comprehensive staffing plan. Prior to the launch of this contract, and if needed on an ad hoc basis, the Contractor will be required to submit a final staffing plan or changes to their staffing plan to the state for review.

The key staff positions required across the four programs include:

Plan President/CEO

· Dedicated full-time to the Contractor’s Indiana Medicaid product lines

· Has full and final responsibility for plan management and compliance with all provisions of the contract. Has clear authority over the general administration and day-to-day activities and financial decisions including rate negotiations.

Chief Financial Officer

· Dedicated full-time to the Contractor’s Indiana Medicaid product lines

· Oversee the budget and accounting systems of the contractor. At a minimum, is responsible for ensuring that the Contractor meets the State's requirements for financial performance and reporting.

Chief Compliance Officer

· Dedicated full-time to the Contractor’s Indiana Medicaid product lines

· Responsible for developing and implementing a compliance program and policies and procedures designed to ensure compliance with all contract requirements. Must maintain a current knowledge of federal and state legislation, legislative initiatives and regulations that may impact Indiana Medicaid. Is the primary liaison with the State (or its designees) to facilitate communications between FSSA, the State’s contractors and the Contractor’s executive leadership and staff.

Chief Information Officer

· Dedicated full-time to the Contractor’s Indiana Medicaid product lines

· Must have the necessary training and experience in information systems, data processing, and data reporting to oversee all information systems functions supporting the state. Oversee the Information Technology (IT) systems and serve as a liaison between the Contractor and the State fiscal agent or other FSSA contractors regarding encounter claims submissions, capitation payment, member eligibility, enrollment and other data transmission interface and management issues. Responsible for ensuring all program data transactions are in compliance with the terms of the Contract and accountable for the overall IT security of systems and data used in support of the work described in this SOW. Required to attend all Technical Meetings called by the State. Ensure that member and provider facing websites and portals are easily navigable by the general public, members, and providers by obtaining and incorporating feedback from these stakeholders. Ensure that Information Technology projects are implemented timely and correctly.

Chief Medical Officer (CMO)

· Dedicated full-time to the Contractor’s Indiana Medicaid product lines

· Must be a physician with a current Indiana license. Must have at least three (3) years of training in a medical specialty. Responsibilities include but are not limited to: a) Ensures MCO makes timely medical decisions; b) Leads all major clinical, population health management, and quality improvement components of the MCO; c) Develops, implements, and interprets medical policies and procedures, including service authorizations, claims review, discharge planning, and medical reviews performed through the MCO grievance and appeal system; d) Leads the administration of all medical management activities of the MCO; and e) Serves as the director of utilization management committee and chairperson or co-chair of the Quality Assessment and Performance Improvement (QAPI) committee.

Behavioral Health Administrative Director

· Dedicated full-time to the Contractor’s Indiana Medicaid product lines

· Must hold an Indiana license as a MD, DO, APRN, Psychologist, LCSW, or other licensed health care professional, with a minimum of five (5) years’ experience in the provision of mental illness and substance use disorders services. Must demonstrate knowledge and understanding of Indiana's behavioral health system that includes mental health, alcohol and drug addiction, and other populations. Ensures access to behavioral health services. Promotes preventive behavioral health strategies. Identify and coordinate assistance for member needs specific to behavioral health. Participates in management and program improvement activities. Enhanced integration with primary care and coordination of behavioral health services. Must have experience with MRO and 1915(i) services, including developing policies and procedures for coordinating services.

Population Health Director

· Dedicated full-time to the Contractor’s Indiana Medicaid product lines

· Holds a master's degree or other advanced degree in nursing, social work, health services research, health policy, information technology, or other relevant field. Has at least five (5) years of progressively responsible professional experience in population health, service coordination, ambulatory care, community public health, case or care management, or coordinating care across multiple settings and with multiple providers. Oversee the MCO's strategic design, implementation, and evaluation of population health initiatives based on a deep understanding of scientific population health principles. Liaison with State and other contracted MCOs on population health strategies. Develop and implement operational plans that address the market opportunities/challenges and align with the established population health goals.

Utilization Management Director

· Dedicated full-time to the Contractor’s Indiana Medicaid product lines

· Must be a registered nurse or physician with a current Indiana license. Be certified as a Certified Professional in Health Care Quality by the NAHQ and/or CHCQM by the American Board of Quality Assurance and Utilization Review Providers. Report through the Chief Medical Officer. Oversees the day-to-day activities of the UM program. Develops written policies and procedures regarding authorization of services and monitors to ensure compliance. Ensure the consistent application of review criteria for authorization decisions. Evaluate under and over utilization information for impact on member quality of care and outcomes, including access to care. Directs staff performance regarding authorizations, medical necessity determinations, concurrent review, retrospective review, appropriate utilization of health care services, continuity of care, care coordination and other clinical and medical management programs. Works with the Special Investigation Unit (SIU) to ensure that service billing and utilization issues are documented and reported to the SIU, and matters requiring SIU review or investigation are timely to enable recovery of overpayments or other appropriate action.

Quality Improvement Director

· Dedicated full-time to the Contractor’s Indiana Medicaid product lines

· Must be a registered nurse or physician with a current Indiana license or be certified as a Certified Professional in Health Care Quality by the NAHQ and/or CHCQM by the American Board of Quality Assurance and Utilization Review Providers. Have experience in quality management and quality improvement as specified in 42 CFR 438.206 through 438.370. Reports directly to the CMO. Develop and manage the MCO's portfolio of improvement projects, including ensuring impact at a population level and identifying and prioritizing initiatives to align with the State's Quality Strategy. Oversee MCO improvement teams and coordinate QI training for MCO staff. Responsible for directing the activities of the Contractor’s quality management staff in monitoring and auditing the Contractor’s health care delivery system, including, but not limited to, internal processes and procedures, provider network(s), service quality and clinical quality. Assist the Contractor’s Compliance Officer in overseeing the activities of the Contractor’s operations to meet the State’s goal of providing health care services that improve the health status and health outcomes.

Chief Operating Officer

· Dedicated full-time to the Contractor’s Indiana Medicaid product lines

· Responsible for oversight of all day-to-day operations of the healthcare plan operations. Has oversight of all functional operational areas within the healthcare plan.

Pharmacy Director

· Dedicated full-time to the Contractor’s Indiana Medicaid product lines

· Must be a registered pharmacist licensed in Indiana with experience in state and federally funded health care programs, preferably with pharmacy benefit management experience. Oversees the MCO's responsibilities related to pharmacy benefits. Coordinates with the State to provide input in the review of new drugs, changes to PDL and authorization criteria. Oversees the medication therapy management programs. Monitors, manages, and coordinates the care of the MCO's members as it relates to utilization of prescription drugs. Must participate in meetings such as the State's Drug Utilization Review (DUR) Board meetings and the Mental Health Quality Advisory Committee (MHQAC), and any other state required meetings.

Grievance and Appeal Director

· Dedicated full-time to the Contractor’s Indiana Medicaid product lines

· Ensures grievance and appeals system functions as an essential process to remediate member access to care and quality concerns, and as a source of information that serves as indicators of health care system issues and concerns. Required to share and review grievance and appeal data with other operational areas to develop and monitor interventions to correct deficiencies. Develops and implements policies and procedures that ensure appropriate action to resolve and close grievance and appeals in a timely manner as required in the contract.

Member Services Director

· Dedicated full-time to the Contractor’s Indiana Medicaid product lines

· Must be located in Indiana. Is responsible for leading and coordinating communications with members, processes for resolving member inquiries and problems and meeting member service requirements. At a minimum, be responsible for communications with members, helpline performance, member electronic communications, member outreach and education, member website, development, approval, and distribution of member materials. May include members impacted by population health programs on the project team to identify member-perceived barriers and to assist with the design and testing of interventions impacting members. Is responsible for ensuring that member perspectives and feedback are included in evaluating programmatic success.

Network Development Director

· Dedicated full-time to the Contractor’s Indiana Medicaid product lines

· Responsible for network development, network sufficiency, and network reporting functions. Ensures network adequacy and appointment access, develops network resources in response to identified unmet needs and oversees network provider workforce development activities. Responsible for provider recruitment, provider contracting, and provider credentialing. Oversees the process of providing information to the state fiscal agent regarding the contractor's provider network. Responsible for ensuring all provider network standards are compliant with contract requirements and state and federal requirements.

Provider Services Director

· Dedicated full-time to the Contractor’s Indiana Medicaid product lines

· Acts as the primary point of accountability to the State to address escalated provider issues. At a minimum, is responsible for provider helpline and helpline performance, facilitating provider claims dispute process, developing and distributing the provider manual and education materials, and developing provider outreach. Is responsible for ensuring provider website and provider directory are compliant with contract requirements.

Special Investigation Unit Director

· Dedicated full-time to the Contractor’s Indiana Medicaid product lines

· Must be located in Indiana. Is responsible for directing the activities of Special Investigation Unit staff, attending meetings with FSSA and reducing or eliminating wasteful, fraudulent, or abusive healthcare billings and services. Responsible to coordinate the timeliness, accuracy, and completeness of all suspected or confirmed instances of waste, fraud, and abuse referrals to the OMPP PI Section. The SIU Director must report to the Compliance Officer and meet with the OMPP Program Integrity (OMPP PI) section as directed by the OMPP PI Section. The SIU Director must be a subject matter expert in Medicaid program integrity and hold qualifications similar to those of state program integrity section managers. Must have experience in analyzing health care claims and coding.

Dental…