Supervisor Professional Claims Review

Location: Augusta,Maine,United States

Department of Health and Human Services (DHHS)

Opening Date: February 14, 2025

Closing Date: February 28, 2025

Job Class Code: 5082

Grade: 25 (Supervisory Services)

Salary: $57,408.00 - $81,078.40 per year

Position Number: 02031-2337

Location: Augusta

Only Employees with Promotional Status in the Department of Health and Human Services May Apply

Core Responsibilities:

As Supervisor Professional Claims Review, you will oversee the day-to-day activities of the Claims Adjustment Unit.   You will provide supervision, leadership and direction to seven full-time staff and have primary responsibility for ensuring the unit consistently and effectively provides resources and support to MaineCare providers and members, as well as other state/federal agencies.  You will help staff interpret MaineCare policy and support them in resolving complicated claims problems.  You will review policies and procedures and make recommendations for development and revision of MaineCare policies/procedures as appropriate.  You will partner with technical staff and other program staff to identify and resolve ongoing issues with the MaineCare Claims Management System.

Minimum Qualifications:

A Bachelors Degree in Public Health, Nursing, Community Health, Health Administration, or related field and four (4) years administrative and/or supervisory experience in the areas of hospital, public health, chronic disease, nursing, or related field -OR- acceptable equivalent combination of education and related professional experience.  

Preference will be given to those with customer contact experience in a related healthcare environment, and significant health plan provider relations experience and at least two years’ experience explaining and interpreting Medicaid rules and regulations.

The background of well-qualified candidates will demonstrate the following competencies: 

1.    An ongoing commitment to OMS organizational core values of accountability, integrity, respect, customer service, collaboration, and personal growth. 
2.    A proven ability to investigate and resolve complex medical and insurance billing issues.
3.    A proven ability to explain complex technical information to consumers and others. 
4.    A history that demonstrates effective leadership, coaching and supervisory skills.  

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Agency information: 

The Department of Health and Human Services (DHHS) is dedicated to promoting health, safety, resilience, and opportunity for Maine people. The Department provides health and social services to approximately a third of the State's population, including children, families, older Mainers, and individuals with disabilities, mental illness, and substance use disorders. The Department also promotes public health, operates two state psychiatric hospitals, and provides oversight to health care providers.

The Office of MaineCare Services (OMS) within DHHS administers the state’s Medicaid program, which provides health insurance coverage for low-income families, adults and children so they can access the important health care services they need to be healthy and be a part of the community through work, caring for family, going to school, and more. OMS works collaboratively within DHHS, with other Departments and the Office of the Governor, with MaineCare members, with providers, and with other health care purchasers on statewide healthcare improvement initiatives. OMS is committed to advancing health equity efforts to improve access to care and health outcomes for all low-income Mainers. OMS provides benefit coverage and supports the services that operate in alignment with Department goals, federal mandates and State policy. OMS also provides oversight necessary to ensure accountability and efficient and effective administration.  

The Claims Adjustment Unit within OMS supports health care providers enrolled with MaineCare by performing claim adjustments for appropriate and accurate reimbursement related to rate changes, CR and TR changes, provider requested adjustments, and other identified claim adjustments to assure compliance with MaineCare policy.

Application Information:

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