MEDICAL CARE PROGRAM SPECIALIST II

Maryland AG; Baltimore, Northern (MD, KY); Hybrid; USD 70,000 - 110,000; Full time

Job summary

Maryland Office of the Inspector General for Health (OIGH) seeks a Regulatory Compliance Investigator to perform audits and investigations across Maryland’s Medicaid population. You will determine beneficiary eligibility, verify applications, and assess compliance with state and federal rules.

The role involves confidential investigations, coordination with multiple MDH units, and production of formal reports with enforceable recommendations. HIPAA and regulatory standards guide all activities.

Qualifications

• Seven years of experience developing or applying policies and regulations in medical assistance or health programs.
• Substitution options allow degrees or military service in related fields.
• Experience working with Medicaid or entitlement programs is preferred.

Responsibilities

• Investigate fraud, waste and abuse in Medicaid programs and determine eligibility.
• Perform audits and follow up reviews of MDH administrations and partner agencies.
• Prepare formal reports with recommendations for potential recovery or prosecutions.
• Ensure HIPAA and COMAR compliance in all activities.

Skills

Policy development

Regulatory compliance

Interviewing subjects

Information gathering

Education

Bachelor's degree substituted with 3 years relevant experience

Master's degree substitution for experience

Military service in health-related field (year-for-year) substitution

Job description

GRADE

STD0016

LOCATION OF POSITION

MDH Office of the Inspector General for Health

Baltimore, MD 21201

MAIN PURPOSE OF JOB

The Maryland Office of the Inspector General for Health (OIGH) is charged with investigating fraud, waste, and abuse (FWA) within the Medicaid Program and seeking the recovery of inappropriate payments across both provider and recipient fraud lines.

Operating as a Regulatory Compliance Investigator within the Program Integrity – Recipient Reviews Unit, this position utilizes target-centric fraud-detection methodologies to actively determine if Medicaid beneficiaries are eligible for services and truthful in their application for benefits.

The incumbent performs the full range of audits and investigations across Maryland’s population of approximately 1.1 million Medicaid recipients.

This position is responsible for performing objective examinations and follow-up reviews of the accounts, records, procedures, and policies of MDH administrations, facilities, Local Health Departments (LHD) and local Departments of Social Services (LDSS) to ensure that all are in compliance with state and federal regulations pertaining to determinations of Medicaid eligibility.

The investigator participates in ongoing investigative activities involving the Maryland Health Insurance Program, Department of Corrections and Public Safety (DCPS), Vital Statistics Death Matches, and the Department of Human Resources (DHR) Medicaid Investigations.

These specific and unique duties are frequently of a confidential and sensitive nature and are conducted in accordance with The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and COMAR 10.09.24 and 10.09.36.

This position ensures that private health information entrusted to the Department is appropriately protected from disclosure.

Each audit, investigation, or inspection results in a formal report with enforceable recommendations, which may include benefit adjustments, financial recoveries, and referral for civil or criminal fraud prosecutions.

MINIMUM QUALIFICATIONS

• Experience: Seven years of administrative or professional experience developing or applying policies and regulations in medical assistance, health insurance, federal or State entitlement programs.
• 1. Candidates may substitute the possession of a Bachelor's degree from an accredited college or university and three years of administrative or professional experience developing or applying policies and regulations in medical assistance, health insurance, federal or State entitlement programs for the required experience.
• 2. Candidates may substitute the possession of a Master’s degree from an accredited college or university in the related field of work for the required experience.
• 3. Candidates may substitute U.S. Armed Forces military service experience as a commissioned officer in Operational Analysis classifications or Health Services Management specialty codes in the health-related field of work on a year-for-year basis for the required experience.

DESIRED OR PREFERRED QUALIFICATIONS

• Experience determining Medicaid eligibility, including experience working with Medicaid policies and procedures.
• Experience accessing the Maryland Health Connection website to retrieve information and documents.
• Experience interviewing subjects to pertinent elicit information.
• Experience researching government websites, social media, and other public websites to access and retrieve information.
• Experience drafting letters and investigative reports.
• Experience using Google Drive and spreadsheets.

LICENSES, REGISTRATIONS AND CERTIFICATIONS

Employees in this classification may be assigned duties which require the operation of a motor vehicle. Employees assigned such duties may be required to possess a motor vehicle operator's license valid in the State of Maryland.

SELECTION PROCESS

Applicants who meet the minimum (and selective) qualifications will be included in further evaluation.

The evaluation may be a rating of your application based on your education, training and experience as they relate to the requirements of the position.

Complete applications must be submitted by the closing date.

The resulting certified eligible list for this recruitment may be used for similar positions in this or other State agencies.

Candidates may remain on the certified eligible list for a period of at least one year.

BENEFITS

DIVERSITY & INCLUSION

Appropriate accommodations for individuals with disabilities are available upon request by calling: 410-767-1251 or MD TTY Relay Service 1-800-735-2258.

We thank our Veterans for their service to our country.

People with disabilities and bilingual candidates are encouraged to apply.

As an equal opportunity employer, Maryland is committed to recruitment, retaining and promoting employees who are reflective of the State's diversity.

CONTACT INFORMATION

For questions regarding this recruitment, please contact the MDH Recruitment and Selection Division at 410-767-1251.

If you are having difficulty with your user account or have general questions about the online application system, please contact the MD Department of Budget and Management, Recruitment and Examination Division at 410-767-4850 or [e-mail].