Program Integrity Analyst I

State-of-Maine; Augusta (ME); On-site; USD 52,000 - 72,000; Full time

Benefits offered by this job

Health Insurance Coverage

Retirement Plan

Gym Membership Reimbursement

Parental leave

Public Service Student Loan Forgivenes

Job summary

State of Maine seeks a Comprehensive Health Planner I to lead studies identifying fraud, abuse, and waste in the MaineCare program using data analytics. You will review large claims datasets, flag unusual patterns, and follow up with investigations and provider compliance checks.

The role requires strong written communication, knowledge of billing/coding, and proficiency with MS Excel, Word, Access, and SharePoint. Location: Augusta, Maine; salary and benefits reflect state government standards.

Qualifications

• Bachelor’s degree and two years of experience in planning, development, coordination and/or evaluation of health programs or services, or a six-year equivalent.
• Ability to identify, research and analyze a broad range of documents and data related to healthcare services and/or eligibility to verify compliance or identify potential fraud.
• Knowledge of nationally accepted billing forms and coding.
• Exceptional written communication to develop reports summarizing compliance/non-compliance.
• Experience with medical terminology, Excel or similar spreadsheets, Word, Access and SharePoint.

Responsibilities

• Direct and conduct studies to identify fraud, abuse and waste in MaineCare using data analytics and other programs.
• Analyze large volumes of claims data to identify unusual billing patterns and high-cost providers for follow-up.
• Review allegations of fraud and abuse and conduct routine provider reviews for MaineCare compliance.
• Determine non-compliance areas and calculate overpayments; prepare detailed case findings.
• Draft recoupment or sanction letters when appropriate and assist in investigations with other units.

Skills

Data analysis

Billing/coding knowledge

Written communication

Medical terminology

Excel

Word processing

Access database

SharePoint

Education

Bachelor’s Degree in Public/Community Health or related field

Tools

SharePoint

Job description

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 IOpening Date: October 28, 2026Closing Date: November 10, 2026Job Class Code: 5049Grade: 23 (Pro. & Tech. Services)Salary: $51,500.80 – $72,259.20 per yearPosition Number: 02000-3381Location: AugustaCore 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:1. 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.2. Knowledge of and experience with nationally accepted billing forms and coding.3. Exceptional written communication skills to include the ability to develop written reports that summarize compliance/non-compliance.4. 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.Thinking about applying?Research shows that people from historically excluded communities tend to apply to jobs only when they check every box in the posting. If you’re currently reading this and hesitating to apply for that reason, we encourage you to go for it! Let us know how your experience and passion set you apart.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].To apply, please upload a resume, cover letter addressing the four competency areas identified in the Requirements Section, and copies of post-secondary transcripts. Applications must be received by the closing date.Please submit all documents or files in PDF or Word format.To request a paper application, please contact [e-mail] of working for the State of Maine:No matter where you work across Maine state government, you find employees who embody our state motto—\"Dirigo\" or \"I lead\"—as they provide essential services to Mainers every day. We believe in supporting our workforce's health and wellbeing with a valuable total compensation package, including:Work-Life Fit – Rest is essential. Take time for yourself using 13 paid holidays and 3+ weeks of vacation leave annually. Vacation leave accrual increases with years of service, and overtime-exempt employees receive personal leave. When you or immediate members of your family are ill, utilize 12 days of sick leave per year.Health Insurance Coverage – The State of Maine pays 85%-95% of employee-only premiums ($12,213.60 - $13,650.48 annual value) , depending on salary. Use this chart to find the premium costs for you and your family, including the percentage of dependent coverage paid by the State.Health Insurance Premium Credit – Participation decreases employee-only premiums by 5% . Visit the Office of Employee Health and Wellness for more information about program requirements .Dental Insurance – The State of Maine pays 100% of employee-only dental premiums ($365.28 annual value).Retirement Plan – The State contributes the equivalent of 14.06% of the employee's pay towards the Maine Public Employees Retirement System (MainePERS), on behalf of the employee.Gym Membership Reimbursement – Improve overall health with regular exercise and receive up to $40 per month to offset this expense.Health and Dependent Care Flexible Spending Accounts – Set aside money pre-tax to help pay for out-of-pocket health care expenses and/or daycare expenses.Public Service Student Loan Forgiveness – The State of Maine is a qualified employer for this federal program. For more information, visit the Federal Student Aid office .Living Resources Program – Navigate challenging work and life situations with our employee assistance program.Parental leave is one of the most important benefits for any working parent. All employees who are welcoming a child—including non-birthing and adoptive parents—receive six weeks of fully paid parental leave . Additional, unpaid leave may also be available, under the Family and Medical Leave Act .Voluntary Deferred Compensation – Save additional pre-tax funds for retirement in a MaineSaves 457(b) account through payroll deductions.State employees are eligible for an extensive and highly competitive benefits package , covering many aspects of wellness. Learn about additional wellness benefits for State employees from the Office of Employee Health and Wellness .Note: Benefits may vary somewhat according to specific collective bargaining agreements and are prorated for anything less than full-time.There's a job and then there's purposeful, transformative work. Our aim is to create a workplace where you can learn, grow, and continuously refine your skills. Applicants demonstrate job requirements in differing ways, and we appreciate that many skills and backgrounds can make people successful in this role.As an Equal Opportunity employer, Maine State Government embraces a culture of respect and awareness. We are committed to creating a strong sense of belonging for all team members, and our process ensures an inclusive environment to applicants of all backgrounds including diverse race, color, sex, sexual orientation or gender identity, physical or mental disability, religion, age, ancestry, national origin, familial status or genetics.If you’re looking for a great next step, and want to feel good about what you do, we’d love to hear from you. Please note reasonable accommodations are provided to qualified individuals with disabilities upon request..If you are unable to complete the online application, please contact the Human Resources representative listed on the job opening you are interested in applying for. They will work with you for an alternative method of submitting.