Provider Relations Specialist

Department of Health and Human Services (DHHS) Opening Date: August 21, 2026 Closing Date: September 3, 2026 Job Class Code: 5011 Grade: 20 (Professional & Technical) Salary: $20.68 - $28.88 per hour Position Number: 02000-2530 Location: Augusta Currently, this position is not eligible for visa sponsorship or STEM OPT extensions. Core Responsibilities: This position reports to the Provider Services Manager and is responsible for developing and maintaining expertise in an assigned set of provider types and policies. The individual will provide support for these assigned areas while also developing knowledge of and supporting policies shared across the team. The position will also require a working knowledge of MaineCare member eligibility requirements and classifications to support accurate and effective claims analysis. The individual must be able to manage multiple and evolving priorities in an organized and efficient manner while maintaining composure, professionalism, and sound judgment when addressing challenging situations. Regular duties include: Interpreting and applying MaineCare policies, with a primary focus on the MaineCare Benefits Manual, and providing clear, accurate, and timely guidance to MaineCare providers. This includes communicating policy requirements, clarifying applicable guidance, and assisting providers in understanding their responsibilities and compliance obligations. The position will ensure that provider communications are consistent with established MaineCare policies and procedures and are presented in a clear and professional manner. Researching complex claims data by exporting claims data onto spreadsheets, analyzing claims data, assessing root cause and remediation, and assisting providers with resolution. Collaborating effectively with internal teams across the Office of MaineCare Services (OMS) and the Department of Health and Human Services (DHHS), as well as external vendor partners, to research, analyze, and resolve complex claims issues. This includes working closely with teams responsible for claims processing, policy development and interpretation, utilization management, rate setting, and prior authorization to identify root causes, clarify requirements, and develop appropriate and timely resolutions. The position will also participate in cross-functional workgroups and project teams supporting large-scale initiatives, system changes, policy implementations, and other organizational priorities as needed. Utilizing strong verbal and written communication skills to develop and present provider training and educational materials on MaineCare policy and claims and billing. Training may be for individual providers or for groups, both on-site and virtually. Assisting providers to determine the appropriate provider type and specialty under which to enroll with MaineCare, as determined by the services the provider renders. Representing OMS and the Department by participating in provider forums, stakeholder groups, provider association meetings, and other external meetings to both share policy and billing information and to gather information about policy or billing issues. Minimum Qualifications: A four (4) year combination of training and experience providing a knowledge of health care administration and community health services. Preferred experience includes: Experience with and knowledge of the Medicaid program and/or other health and human services programs serving low-income populations Lived experience with Medicaid and/or other health-related social needs common to individuals and families receiving Medicaid coverage The background of well-qualified candidates will demonstrate the following competencies: A proven ability to investigate and resolve complex medical insurance claims billing issues, and a thorough knowledge of MaineCare provider policies, programs, guidelines, procedures, and processes or similar knowledge in a commercial health plan environment A demonstrated ability to develop and deliver adult training programs to diverse audiences, including comfort with Microsoft PowerPoint Strong analytical and problem-solving skills, including comfort with Microsoft Excel Ability to foster collaborative working relationships with both internal and external stakeholders Ability to work independently on multiple projects while maintaining progress on daily work. #J-18808-Ljbffr