Program Integrity Analyst I

State of Maine•Augusta, GA

About The Position

The Program Integrity Analyst I, listed in the position details as a Comprehensive Health Planner I in the Program Integrity Unit, directs and conducts studies to identify and verify fraud, abuse, and waste in the MaineCare Program. The role uses a data analytics review system and other programs to analyze large volumes of claims data, identify unusual or suspicious billing patterns, and flag outliers and high-volume or high-cost providers for possible follow-up. The analyst reviews allegations of fraud and abuse and conducts routine provider reviews to verify compliance with MaineCare rules and regulations. The position identifies non-compliance, calculates overpayments, prepares detailed spreadsheets of case-review findings, and, when appropriate, drafts recoupment or sanction letters. The analyst also assists the Healthcare Crimes Unit, the Office of Inspector General, and the U.S. Attorney’s Office with investigations requiring MaineCare policy and procedure expertise or additional administrative review. The position is with the Maine Department of Health and Human Services’ Office of MaineCare Services. The Program Integrity Unit provides audit oversight of public assistance funds administered by MaineCare.

Requirements

Bachelor’s degree in Public/Community Health, Health Administration, Health Sciences, Health Education, Public Administration, Government, Social Work, or a closely related field, plus two years of professional experience in planning, developing, coordinating, and/or evaluating health programs or services; alternatively, an equivalent six-year combination of education, training, and experience.
Ability to identify, research, and analyze a broad range of documents and data related to healthcare services and/or eligibility to verify compliance and identify potential fraud.
Knowledge of and experience with nationally accepted billing forms and coding.
Exceptional written communication skills, including the ability to develop reports summarizing compliance and non-compliance.
Knowledge and experience with medical terminology, Excel or a comparable spreadsheet application, MS Word or a comparable word-processing application, Access or a comparable database application, and SharePoint or a comparable file-sharing application.

Responsibilities

Direct and conduct studies to identify and verify fraud, abuse, and waste in the MaineCare Program.
Analyze large volumes of claims data to identify unusual or suspicious billing patterns, outliers, and high-volume or high-cost providers that may require follow-up.
Review and investigate allegations of fraud and abuse.
Conduct routine provider reviews to verify compliance with MaineCare rules and regulations.
Identify areas of non-compliance and calculate overpayment amounts.
Prepare detailed spreadsheets of case-review findings and, when appropriate, draft recoupment or sanction letters.
Assist the Healthcare Crimes Unit, the Office of Inspector General, and the U.S. Attorney’s Office with investigations requiring MaineCare policy and procedure expertise or additional administrative review.

Benefits

13 paid holidays and at least three weeks of annual vacation leave; vacation accrual increases with years of service, and overtime-exempt employees receive personal leave.
12 days of sick leave per year.
State-paid employee-only health insurance premiums, covering 85%–95% depending on salary; a health insurance premium credit may reduce employee-only premiums by 5% when program requirements are met.
State-paid employee-only dental insurance premiums.
State contribution equivalent to 14.06% of employee pay toward MainePERS.
Gym membership reimbursement of up to $40 per month.
Health and dependent care flexible spending accounts.
Eligibility for Public Service Student Loan Forgiveness.
Employee assistance program through the Living Resources Program.
Six weeks of fully paid parental leave for employees welcoming a child, including non-birthing and adoptive parents.
Voluntary deferred compensation through a MaineSaves 457(b) account.
Additional employee wellness benefits; benefits may vary by collective bargaining agreement and are prorated for less than full-time work.