Medical Support Spec Claims

State of Maine • Augusta, ME

4d • $19 - $27 • Hybrid

About The Position

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) Opening Date: March 16, 2026 Closing Date: March 27, 2026 Job Class Code: 6574 Grade: 16 (Administrative Services) Salary: $18.76 - $27.03 per hour Position Number: 020003161 Location: Augusta This position allows for partial telework with management approval. Currently, this position is not eligible for visa sponsorship or STEM OPT extensions. 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, which provides health insurance coverage for low-income families, adults and children so they can access the important health care services they need to be healthy and be a part of the community through work, caring for family, going to school, and more. OMS works collaboratively within DHHS, with other Departments and the Office of the Governor, with MaineCare members, with providers, and with other health care purchasers on statewide healthcare improvement initiatives. OMS is committed to advancing health equity efforts to improve access to care and health outcomes for all low-income Mainers. OMS provides benefit coverage and supports the services that operate in alignment with Department goals, federal mandates and State policy. OMS also provides oversight necessary to ensure accountability and efficient and effective administration. The PHD position is part of the Pharmacy Unit, within OMS. As the only member help desk staffed by MaineCare, the PHD serves a unique role in the office. This high-volume call center position provides time-sensitive telephone assistance to MaineCare members, internal teams, and external partners. This position reports to the MaineCare Pharmacy Help Desk Supervisor. This is a full-time position located at 109 Capitol Street, Augusta, Maine.

Requirements

• Training, education, or experience in office and administrative support work that demonstrates competency in applying a proficient knowledge of medical terminology and medical support functions to perform advanced work in adjusting medical claims errors for adjudication
• the ability to use independent judgment, initiative, and discretion to make determinations on varied matters.

Nice To Haves

• Experience with and knowledge of the Medicaid program and/or other health and human services programs serving low-income populations
• Training and/or experience analyzing, evaluating, and responding to MaineCare and/or Medicare Part D claims processing and practices
• Lived experience with Medicaid and/or other health-related social needs common to individuals and families receiving Medicaid coverage
• Knowledge of healthcare benefit programs (e.g., MaineCare and Medicare) with special concentration in Medicare Part D (Prescription Drug Coverage).
• Working experience in a call center with time-sensitive performance metrics.
• Ability in providing kind, courteous, and exceptional customer service.

Responsibilities

• Responds to calls from MaineCare members, pharmacists, and technicians representing various coverage plans.
• Research pharmacy claims and prior authorizations with a depth of knowledge of our Preferred Drug List (PDL).
• Educates MaineCare members regarding various Medicare Part D Medicare Savings Program/Medicare buy-in plans including how to choose a plan and how the plan pays benefits.
• Assist MaineCare members with enrollment process.
• Reviews insurance coverage for pharmacies, doctor’s offices, hospitals, MaineCare members, and other identified individuals/organizations.
• Evaluates claims processing.
• Assist MaineCare members with problems related to co-pays, deductibles, premiums, or other related issues.
• Assist MaineCare members who are out of medication or are unable to fill prescriptions.

Benefits

• Work-Life Fit – Rest is essential. Take time for yourself using 13 paid holidays, 12 days of sick leave, and 3+ weeks of vacation leave annually. Vacation leave accrual increases with years of service, and overtime-exempt employees receive personal leave.
• Health Insurance Coverage – The State of Maine pays 85%-100% of employee-only premiums ($12,845.82 - $15,112.76 annual value), depending on salary.
• Health Insurance Premium Credit – Participation decreases employee-only premiums by 5%.
• Dental Insurance – The State of Maine pays 100% of employee-only dental premiums ($395.72 annual value).
• Retirement Plan – The State contributes the equivalent of 14.11% of the employee's pay towards the Maine Public Employees Retirement System (MainePERS).
• 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.
• State employees are eligible for an extensive and highly competitive benefits package, covering many aspects of wellness.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed