Medical Support Specialist- Claims

Location: Augusta, Maine,None,None

Department of Health and Human Services (DHHS)

Opening Date: April 22, 2025        

Closing Date: May 5, 2025

Job Class Code: 6574

Grade:  16 (Administrative Services)

Salary: $18.76 - $27.03 per hour

Position Number:  02031-2353

Location: Augusta

Core Responsibilities:

As a Medical Support Specialist, you will work with a team that reviews claims and claims data from the MaineCare claims processing system and the accuracy of the work of the Claims Division staff. You will use a variety of standard desktop reporting tools such as Microsoft Word, Outlook and Excel to compile, test and report review results.  Desired skills include:

1.     Prior experience working with an enterprise-level database.
2.    Skilled in using Microsoft Outlook, Word and Excel.
3.    The ability to work with a small team to meet targets and improve systems.
4.    The ability to work independently.
5.    Background in insurance claim processing. 
6.    Knowledge of (HIPAA) Health Insurance Portability and Accountability Act.
7.     A basic knowledge of HCPC, CPT and ICD-9 guidelines.
8.    Prior experience performing accounts payable functions.
9.    The ability to analyze complex medical claims for adjusted payments

Minimum Qualifications:

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 and 2) the ability to use independent judgment, initiative, and discretion to make determinations on varied matters.

The background of well-qualified candidates will include the following competencies:
 (1) The ability to review medical claims for payment, adjudication or adjustments for accuracy and conformance with established policies and practice.
 (2) Skilled in the use of MIHMS or a comparable automated medical claims system.
 (3) The ability to compile program data and produce automated management information reports summarizing program performance.

Agency information: 

The Department of Health and Human Services (DHHS) provides supportive, preventive, protective, public health and intervention services that safeguard the public health and assist families and individuals to meet their needs. DHHS strives to provide these programs and services while respecting the rights and preferences of individuals and families.

The Office of MaineCare Services (OMS) within DHHS administers the state’s Medicaid program and coordinates several major healthcare financing programs for Maine, including the Children’s Health Insurance Program (CHIP). OMS works collaboratively with the Commissioner’s Office of DHHS and the Office of the Governor on health reform and coordinates with other health plans on statewide healthcare improvement initiatives. OMS ensures that the healthcare programs and services it administers operate in alignment with DHHS goals and federal mandates and are consistent with State policy. OMS also provides oversight necessary to ensure accountability and efficient and effective administration. The Claims Adjustment Division oversees the re-processing of claims for MaineCare members that may need to be adjusted or reprocessed including enforcing claims policies and rules and resolving problematic claims.  

Thinking about applying?

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Application Information:

Please submit all documents or files in PDF format.

For additional information about this position please contact Crystal Breton, Supervisor Claims Adjustment Unit at (207) 624-4023 or by e-mail at Crystal.Breton@Maine.gov

To apply online, please select the “Apply for this opening” button, upload a resume and cover letter addressing the competency areas listed above. 

To request a paper application, please contact Mandy Hernandez at Mandy.Hernandez@Maine.gov 

Benefits of working for the State of Maine:

No matter where you work across Maine state government, you find employees who embody our state motto—"Dirigo" or "I lead"—as they provide essential services to Mainers every day. We believe in supporting our workforce's health and wellbei