Nurse Manager of Medical Frailty

Purpose of Position/Summary:

The Manager of Medical Frailty supports the client in overseeing the complex classification of Healthy 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 client, and other partners to ensure compliance with client requirements.

This role 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 client 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 the client to ensure accurate eligibility pathways for medically frail members.
Coordinate with the client 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 the client medically frail requirements.
Identify patterns of over- and under-designation and implement corrective action plans.
Ensure the client 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 (IN 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 client regulation's and apply them to complex clinical scenarios.

Skill - Required / Desired - Amount of Experience
IN Licensed/or Compact State Licensed RN or NP with current unencumbered license. - Required
Bachelor's degree in nursing. - Required
Strong knowledge of Medicaid programs, eligibility pathways and medically frail criteria. - Required - 3 Years
Experience with clinical assessment, disability determination, care management or utilization review. - Required - 3 Years
Ability to interpret client regulations and apply them to complex clinical scenarios - Required - 3 Years
Prior experience utilizing data analysis and analytics, interpreting regulations. - Required - 3 Years
Ability to work autonomously with strong judgment and decision making skills. - Required
Prior experience with complex physical or behavioral conditions. - Highly desired
Prior experience in a management role, preferably UM or case management team. - Highly desired

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 client leadership, MCOs, actuarial teams, analytics teams, and external partners. Must be able to represent the client'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.

Notes:
Position is on-site Monday thru Friday, 7.5H days, 37.5H week.