Program Integrity Analyst I
Core
Conduct data analytics reviews and investigations to identify, verify, and calculate fraud, abuse, and waste in the MaineCare Medicaid program.
Role type
Program Integrity Analyst (Healthcare Fraud Investigation)
Builds
Compliance reports, recoupment/sanction letters, and case files for the Healthcare Crimes Unit and U.S. Attorney's Office.
Domain
Public Health Administration / Healthcare Fraud Detection
Required skills
Data analytics, claims data analysis, medical billing and coding knowledge, medical terminology, Excel, MS Word, Access, SharePoint
Preferred skills
Knowledge of nationally accepted billing forms, experience with database applications
Responsibilities
Analyze large volumes of claims data to identify suspicious billing patterns and outliers; review and investigate allegations of fraud and abuse; conduct routine provider compliance reviews; calculate overpayment amounts; draft recoupment and sanction letters; assist in case investigations with the Healthcare Crimes Unit and U.S. Attorney's Office.
Seniority
Entry-level (I), requires Bachelor's degree and 2 years experience
