Program Integrity Analyst I
About The Position
The Program Integrity Analyst I is a Comprehensive Health Planner I in the Program Integrity Unit of the Maine Department of Health and Human Services’ Office of MaineCare Services. The position directs and conducts studies to identify and verify fraud, abuse, and waste in the MaineCare Program, using a data analytics review system and other programs. It analyzes large volumes of claims data to identify unusual or suspicious billing patterns, outliers, and providers with high billing volume or costs that may need additional follow-up. The analyst reviews allegations of fraud and abuse and conducts routine provider reviews to verify compliance with MaineCare rules and regulations. The role identifies non-compliance, calculates overpayments, prepares detailed spreadsheets of 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 case investigations requiring MaineCare policy and procedure expertise or additional administrative review. The Program Integrity Unit provides audit oversight of public assistance funds administered by the MaineCare Program. This position is based in Augusta. The listed salary is $51,500.80–$72,259.20 per year.
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, development, coordination, and/or evaluation of 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/or identify potential fraud.
- Knowledge of and experience with nationally accepted billing forms and coding.
- Exceptional written communication skills, including the ability to develop written reports summarizing compliance and non-compliance.
- Knowledge and experience with medical terminology, Excel or comparable spreadsheet applications, MS Word or comparable word-processing applications, Access or comparable database applications, and SharePoint or comparable file-sharing applications.
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 requiring follow-up.
- Review and investigate allegations of fraud and abuse.
- Conduct routine provider reviews to verify compliance with MaineCare rules and regulations.
- Determine areas of non-compliance and calculate overpayment amounts.
- Prepare detailed spreadsheets of case review findings.
- Draft recoupment or sanction letters when appropriate.
- Assist the Healthcare Crimes Unit, Office of Inspector General, and 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 service, and overtime-exempt employees receive personal leave.
- 12 days of sick leave per year.
- State-paid portion of employee-only health insurance premiums (85%–95%, depending on salary) and a health insurance premium credit opportunity.
- State-paid employee-only dental insurance premiums.
- State contribution equivalent to 14.06% of pay toward MainePERS retirement.
- 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; additional unpaid leave may be available under the Family and Medical Leave Act.
- Voluntary deferred compensation through a MaineSaves 457(b) account.
- Additional wellness benefits; benefits may vary by collective bargaining agreement and are prorated for less-than-full-time work.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
