Maine Department of Health and Human Services Direct Hire Vacancy Announcement Comprehensive Health Planner I Division of Audit - Program Integrity 2 vacancies

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CODE:  5049		 RANGE:  23 (Pro. & Tech. Svcs.)	       $35,859.20 - $48,526.40/yr.

Value of State-paid Health & Dental Insurance:  $341.08 biweekly (90% State contribution).

Value of State's share of employee's retirement:  11.54% of pay.

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Opening Date: January 18, 2013	Contact:	W. Malinowski
Closing Date: February 1, 2013	Telephone:	(207) 287-4289
Location: Augusta

Agency Information

The Department of Health and Human Services (DHHS) provides supportive, preventive, protective, public health and intervention services that protect the public health and assist our customers in meeting their needs; and that assist families in providing for the developmental, health and safety needs of their children. DHHS strives to provide these programs and services while respecting the rights and preferences of individuals and families.


DHHS contracts with organizations throughout the State to provide health care and social services to Maine's citizens. These sub-recipient organizations include hospitals, nursing homes, residential care facilities, private non-medical institutions as well as many non-profit social service agencies. The Program Integrity Unit in the Division of Audit is responsible for providing audit oversight services of public assistance funds administered by the MaineCare Program. We currently have 2 vacancies in our Augusta office.

Job Duties

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 the Decision Support System (DSS) 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.

Requirements

To qualify, you must have a Bachelors* Degree from an accredited educational institution in Public/Community Health, Health Administration, Public Administration, Social Work, or a closely related field and three (3) years of progressively responsible experience in the planning, development and coordination of health programs or services. Directly related experience may be substituted for education on a year-for-year basis. The background of well-qualified candidates will demonstrate the following competencies:

1. An ability to review provider records in order to determine medical necessity and/or the appropriateness of services and/or reimbursement provided in accordance with Medicaid policies and/or comparable healthcare services.

2. Knowledge of and experience with nationally accepted billing forms and coding.

3. 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.

4. Exceptional written communication skills to include the ability to develop written reports that summarize compliance/non-compliance.

5. Please rate your skills in each of the following as expert, skilled or novice:

a. Medical terminology: _____
b. Excel or comparable spreadsheet application: _____
c. MS Word or comparable word processing application: _____
d. Access or comparable database application: _____
e. SharePoint or comparable file sharing application: _____

*Only post-secondary degrees from a College or University whose accreditation has been granted from a nationally recognized accreditation agency recognized by the U.S. Secretary of Education will satisfy educational requirements. Information can be obtained at http://www.ope.ed.gov/accreditation/. Foreign degrees must be evaluated by the World Education Services for authentication and U.S. equivalency.