Program Integrity Analyst I

Department of Marine Resources; Augusta (ME); Vor Ort; USD 52.000 - 72.000; Vollzeit

Zusammenfassung

Department of Health and Human Services in Augusta seeks a Comprehensive Health Planner I to lead data-driven reviews identifying fraud, abuse and waste in MaineCare. You will analyze large claims datasets, verify compliance, and draft recoupment or sanction letters as appropriate.

Responsibilities include coordinating with Healthcare Crimes Unit and other authorities, and preparing detailed reports to support investigations and program improvement efforts.

Qualifikationen

• Bachelor's degree with 2 years health program planning/coordination experience.
• Or an equivalent six-year education/experience combination.

Aufgaben

• Direct and conduct studies to identify fraud, abuse, and waste in MaineCare.
• Analyze large claims data to find unusual or suspicious patterns.
• Investigate allegations and review providers for compliance with MaineCare rules.
• Prepare detailed case findings and assist in recoupment letters when needed.

Kenntnisse

Data analysis

Written communication

Billing forms

Billing codes

Excel

Word processing

Access

SharePoint

Ausbildung

Bachelor's degree in Public/Community Health or related field

Tools

Excel

Word

Access

SharePoint

Jobbeschreibung

If you are a current State of Maine employee, please submit your application through the internal application process using the Find Jobs report in PRISM. Seasonal employees who do not have PRISM access should apply through the State's career page and indicate on the application that they have previously worked for the State.

Department of Health and Human Services (DHHS)

Comprehensive Health Planner I

Opening Date: October 28, 2026

Closing Date: November 10, 2026

Job Class Code: 5049

Grade: 23 (Pro. & Tech. Services)

Salary: $51,500.80 - $72,259.20 per year

Position Number: 02000-3381

Location: Augusta

Core Responsibilities

As a Comprehensive Health Planner I in the Program Integrity Unit, you will direct and conduct studies to identify and verify areas of fraud, abuse and waste in the MaineCare Program by using a data analytics review system among other programs. You will analyze large volumes of claims data to identify unusual or suspicious billing patterns, outliers, high volume or cost providers that may require additional follow-up. You will review/investigate allegations of fraud and abuse and conduct routine reviews of providers to verify compliance with MaineCare rules and regulations. You will determine areas of non-compliance and calculate overpayment amounts. You will prepare detailed spreadsheets of case review findings and when appropriate draft recoupment/sanction letters. You will assist the Healthcare Crimes Unit, OIG and the U.S. Attorney's Office in case investigations when MaineCare policy and procedure expertise is required and/or when additional administrative review is needed.

Minimum Qualifications

A Bachelor's Degree in Public/Community Health, Health Administration, Health Sciences or Health Education; Public Administration, Government, Social Work ,or a closely related field and two (2) years professional experience in the planning, development, coordination and/or evaluation of health programs or services -OR- an equivalent six (6) year combination of education, training, and experience.

The background of well-qualified candidates will demonstrate the following competencies

• A demonstrated ability to identify, research and analyze a broad range of documents and data related to healthcare services and/or eligibility in order to verify compliance and/or identify potential fraud.
• Knowledge of and experience with nationally accepted billing forms and coding.
• Exceptional written communication skills to include the ability to develop written reports that summarize compliance/non-compliance.
• Knowledge and experience with medical terminology , Excel or comparable spreadsheet applications, MS Word or comparable word process application, Access or comparable database application and SharePoint or comparable file sharing application.

Agency information

The Department of Health and Human Services (DHHS) is dedicated to promoting health, safety, resilience, and opportunity for Maine people. The Department provides health and social services to approximately a third of the State's population, including children, families, older Mainers, and individuals with disabilities, mental illness, and substance use disorders. The Department also promotes public health, operates two state psychiatric hospitals, and provides oversight to health care providers.

The Office of MaineCare Services (OMS) within DHHS administers the state's Medicaid program and coordinates several major healthcare financing programs for Maine, including the Children's Health Insurance Program (CHIP). OMS works collaboratively with the Commissioner's Office of DHHS and the Office of the Governor on health reform and coordinates with other health plans on statewide healthcare improvement initiatives. OMS ensures that the healthcare programs and services it administers operate in alignment with DHHS goals and federal mandates and are consistent with State policy. OMS also provides oversight necessary to ensure accountability and efficient and effective administration. The Program Integrity Unit in the Office of MaineCare Services is responsible for providing audit oversight services of public assistance funds administered by the MaineCare Program.

Application Information

For additional information about this position please contact Lynne Grivois, Supervisor, Program Integrity Unit, [phone].