Program Integrity Analyst I: Fraud & Compliance Investigator

Department of Health and Human Services; Augusta (ME); On-site; USD 52,000 - 72,000; Full time

Benefits offered by this job

Vacation leave

Health insurance

Dental insurance

Retirement plan

Gym membership reimbursement

Flex spending accounts

Job summary

The Department of Health and Human Services in Augusta, Maine seeks a Comprehensive Health Planner I to lead data-driven reviews and investigations into fraud, abuse, and waste in MaineCare. The role requires analyzing claims data, identifying suspicious patterns, and preparing findings for recoupment or sanctions under the Program Integrity Unit.

The position supports case investigations with the Healthcare Crimes Unit and MaineCare policies, contributing to effective public health program

Qualifications

• 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.

Responsibilities

• Direct and conduct studies to identify fraud, abuse and waste in MaineCare.
• Analyze large volumes of claims data to identify unusual billing patterns.
• Review/investigate allegations of fraud and abuse and conduct routine provider reviews.
• Determine areas of non-compliance and calculate overpayments.
• Prepare detailed spreadsheets and draft recoupment/sanction letters; assist in investigations.

Skills

Billing & coding

Written communication

Data analysis

Medical terminology

Tools

Excel

Word

Access

SharePoint

Job description

The Department of Health and Human Services in Augusta, Maine seeks a Comprehensive Health Planner I to lead data-driven reviews and investigations into fraud, abuse, and waste in MaineCare. The role requires analyzing claims data, identifying suspicious patterns, and preparing findings for recoupment or sanctions under the Program Integrity Unit.

The position supports case investigations with the Healthcare Crimes Unit and MaineCare policies, contributing to effective public health program