Medical Care Program Specialist Ii

STD
0016

MDH Office of the Inspector General for Health

Baltimore, MD 21201

The Maryland Office of the Inspector General for Health (OIGH) is charged with investigating fraud, waste, and abuse (FWA) within the Medicaid Program and seeking the recovery of inappropriate payments across both provider and recipient fraud lines.

Operating as a Regulatory Compliance Investigator within the Program Integrity – Recipient Reviews Unit, this position utilizes target-centric fraud-detection methodologies to actively determine if Medicaid beneficiaries are eligible for services and truthful in their application for benefits.

The incumbent performs the full range of audits and investigations across Maryland’s population of approximately 1.1 million Medicaid recipients.

This position is responsible for performing objective examinations and follow-up reviews of the accounts, records, procedures, and policies of MDH administrations, facilities, Local Health Departments (LHD) and local Departments of Social Services (LDSS) to ensure that all are in compliance with state and federal regulations pertaining to determinations of Medicaid eligibility.

The investigator participates in ongoing investigative activities involving the Maryland Health Insurance Program, Department of Corrections and Public Safety (DCPS), Vital Statistics Death Matches, and the Department of Human Resources (DHR) Medicaid Investigations.

These specific and unique duties are frequently of a confidential and sensitive nature and are conducted in accordance with The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and COMAR 10.09.24 and 10.09.36.

This position ensures that private health information entrusted to the Department is appropriately protected from disclosure.

Each audit, investigation, or inspection results in a formal report with enforceable recommendations, which may include benefit adjustments, financial recoveries, and referral for civil or criminal fraud prosecutions.

• Experience:
  
  Seven years of administrative or professional experience developing or applying policies and regulations in medical assistance, health insurance, federal or State entitlement programs.
• 1. Candidates may substitute the possession of a Bachelor's degree from an accredited college or university and three years of administrative or professional experience developing or applying policies and regulations in medical assistance, health insurance, federal or State entitlement programs for the required experience.
• 2. Candidates may substitute the possession of a Master’s degree from an accredited college or university in the related field of work for the required experience.
• 3. Candidates may substitute U.S. Armed Forces military service experience as a commissioned officer in Operational Analysis classifications or Health Services Management specialty codes in the health-related field of work on a year-for-year basis for the required experience.

• Experience determining Medicaid eligibility, including experience working with Medicaid policies and procedures.
• Experience accessing the Maryland Health Connection website to retrieve information and documents.
• Experience interviewing subjects to pertinent elicit information.
• Experience researching government websites, social media, and other public websites to access and retrieve information.
• Experience drafting letters and investigative reports.
• Experience using Google Drive and spreadsheets.

Employees in this classification may be assigned duties which require the operation of a motor vehicle. Employees assigned such duties may be required to possess a motor…