68039490 - CHIEF OF MEDICAID PROGRAM INTEGRITY-AHCA

State of Florida•Tallahassee, FL

9d•$4,615 - $5,000•Onsite

About The Position

This is a highly responsible position directing the Medicaid Program Integrity operations for the Agency for Health Care Administration. This position has been identified as mission essential. The incumbent in this position may be required to work during the weekend or on holidays. In addition, mission essential personnel will be required to work during disasters, to include but not limited to, work before, during and/or beyond normal work hours or days in the event of an emergency. Emergency work may involve the incumbent to work in another county or staffing location to assist other State Agencies with emergency work. Emergency duties may include, but not limited to, responses to or threats involving any disaster or threat of disaster, man-made or natural. The Chief of Medicaid Program Integrity serves as the Agency's leader responsible for developing, implementing, and directing a comprehensive program integrity strategy designed to prevent, detect, investigate, and audit fraud, abuse, waste, and improper payments in the Medicaid program. The incumbent is responsible for providing strategic leadership for all program integrity operations, audits, investigations, data analytics, managed care oversight, and compliance activities. The Chief of Medicaid Program Integrity is responsible for maintaining a modern, risk-based program integrity framework that aligns operational activities with Agency and organizational goals, regulatory requirements, and recognized best practices. The incumbent leads both short- and long-term strategic planning efforts and directs the assessment of emerging vulnerabilities and risks to ensure that program integrity resources are deployed effectively and maximize a return on investment for the Agency. The incumbent collaborates extensively with the Agency executive leadership, federal and state agencies, law enforcement partners, managed care organization Special Investigations Units, provider associations, and other key stakeholders. The incumbent is responsible for preparing and presenting executive-level reports, briefings, and recommendations to Agency leadership, policymakers, and external partners. The incumbent in this position supervises and spends much of their time communicating with motivating, training, and evaluating employees, and planning and directing employees’ work. Has the authority to hire, transfer, suspend, lay off, re-class, promote, discharge, assign, reward, or discipline subordinate employees or effectively recommend such action, including all employees serving as supervisors, administrators, and directors. Plans, directs, organizes, and coordinates the oversight activities of the Medicaid Program Integrity office to ensure that Medicaid services are delivered in accordance with applicable federal and state laws, rules, regulations, and guidelines. Directs a highly trained staff of varied professional backgrounds, including health care, human services, financial, and investigative professionals. Plans, directs, and organizes operations, administrative functions, field initiatives, and procurements of the office of the Medicaid Program Integrity to include the effective monitoring and oversight of the office’s budget, personnel, and expenditures. Mains up-to-date knowledge concerning the Florida Medicaid Program including pertinent statutes, Florida State plan for Medicaid, Florida administrative code, rules and regulations of the Agency for Health Care Administration, provider manuals, and Medicaid billing procedures, computer processing, statistical analysis software, and information retrieval and management reporting capabilities. Directs the development and implementation of policies and procedures and develops short term and long-range plans for Medicaid Program Integrity, coordinating the development and implementation of policies with other agencies offices, provider groups and associations, fiscal agent contractor, and other local, state, and federal agencies. Initiates, directs, and coordinates audits and investigations of Medicaid providers to identify where program funds are erroneously spent and effectively implements corrective action to eliminate problems. Serves as principal liaison with other entities regarding Medicaid fraud and abuse investigations and utilization control activities in the Medicaid program reviewing and evaluating the impact of such activities on the Medicaid program. Conceptualize and implements new approaches to minimize the extent of fraud and abuse in the Medicaid program; makes recommendations to Agency leadership for improving the efficiency and effectiveness of the program by implementing revisions to policy and reimbursement methods and cost containment measures. This position requires exceptional strategic thinking, sound judgment, and a commitment to protecting program resources. A good attendance record is essential for any individual in this position as the work involved occurs daily and is time-critical. The individual in this position is expected to report to work daily and on time. Leave must be requested in advance except in emergency circumstances not under the control of the employee.

Requirements

Four years of professional work experience which demonstrates leadership and personnel management capability, at least one of which is professional experience in a supervisor position.
Four years professional work experience in a position with duties related to prevention, detection, or investigation of fraud, abuse, or waste in health care, and/or professional work experience in a position within a regulatory, or health services setting.
Knowledge of Federal Medicaid, Florida Medicaid, Florida Law Related to Program Integrity, Federal Law Related to Program Integrity, Florida Program Integrity Procedure, Principles of Program Integrity, Principles of Investigations, and Theory and Principles of Fraud and Criminology.
Knowledge of managed care, provider enrollment, reimbursement, and claims processing.
Knowledge of auditing standards, investigative processes, analytic methodologies, compliance programs, and internal controls.
Proficiency in the use of Word, Excel, and other relevant Agency software.
Strong strategic planning, organizational development, and change management abilities.
Ability to communicate effectively, both verbally and in writing.
Ability to manage and prioritize multiple projects and Agency requirements.
Ability to establish and maintain effective working relationships with others.
Ability to plan, organize and direct timely completion of assignments to the bureau.
Ability to manage staff efficiently and effectively.
Ability to travel with or without accommodation.

Nice To Haves

A graduate degree from an accredited college or university in one of the following disciplines: health law; health sciences; health services administration; business administration; public administration; education; political science/government relations; or a substantially similar discipline, such as criminology or criminal justice.
A program integrity related professional certification, such as: Certified Fraud Examiner; Accredited Healthcare Fraud Investigator; Certified Financial Crimes Investigator; Certified Insurance Fraud Investigator; or Certified Compliance and Ethics Professional.
Additional professional experience beyond four years can substitute on a year-for-year basis for the preferred college education.

Responsibilities

Serves as the Agency's leader responsible for developing, implementing, and directing a comprehensive program integrity strategy designed to prevent, detect, investigate, and audit fraud, abuse, waste, and improper payments in the Medicaid program.
Provides strategic leadership for all program integrity operations, audits, investigations, data analytics, managed care oversight, and compliance activities.
Maintains a modern, risk-based program integrity framework that aligns operational activities with Agency and organizational goals, regulatory requirements, and recognized best practices.
Leads both short- and long-term strategic planning efforts and directs the assessment of emerging vulnerabilities and risks to ensure that program integrity resources are deployed effectively and maximize a return on investment for the Agency.
Collaborates extensively with the Agency executive leadership, federal and state agencies, law enforcement partners, managed care organization Special Investigations Units, provider associations, and other key stakeholders.
Prepares and presents executive-level reports, briefings, and recommendations to Agency leadership, policymakers, and external partners.
Supervises and spends much of their time communicating with motivating, training, and evaluating employees, and planning and directing employees’ work.
Has the authority to hire, transfer, suspend, lay off, re-class, promote, discharge, assign, reward, or discipline subordinate employees or effectively recommend such action, including all employees serving as supervisors, administrators, and directors.
Plans, directs, organizes, and coordinates the oversight activities of the Medicaid Program Integrity office to ensure that Medicaid services are delivered in accordance with applicable federal and state laws, rules, regulations, and guidelines.
Directs a highly trained staff of varied professional backgrounds, including health care, human services, financial, and investigative professionals.
Plans, directs, and organizes operations, administrative functions, field initiatives, and procurements of the office of the Medicaid Program Integrity to include the effective monitoring and oversight of the office’s budget, personnel, and expenditures.
Maintains up-to-date knowledge concerning the Florida Medicaid Program including pertinent statutes, Florida State plan for Medicaid, Florida administrative code, rules and regulations of the Agency for Health Care Administration, provider manuals, and Medicaid billing procedures, computer processing, statistical analysis software, and information retrieval and management reporting capabilities.
Directs the development and implementation of policies and procedures and develops short term and long-range plans for Medicaid Program Integrity, coordinating the development and implementation of policies with other agencies offices, provider groups and associations, fiscal agent contractor, and other local, state, and federal agencies.
Initiates, directs, and coordinates audits and investigations of Medicaid providers to identify where program funds are erroneously spent and effectively implements corrective action to eliminate problems.
Serves as principal liaison with other entities regarding Medicaid fraud and abuse investigations and utilization control activities in the Medicaid program reviewing and evaluating the impact of such activities on the Medicaid program.
Conceptualizes and implements new approaches to minimize the extent of fraud and abuse in the Medicaid program.
Makes recommendations to Agency leadership for improving the efficiency and effectiveness of the program by implementing revisions to policy and reimbursement methods and cost containment measures.

Benefits

Health insurance (i.e., individual and family coverage) to eligible employees
Life insurance; $25,000 policy is free plus option to purchase additional life insurance
Dental, vision and supplemental insurance
State of Florida retirement options, including employer contributions
Ability to earn up to 176 hours of paid annual leave as a new employee with the State of Florida
Ability to earn up to 104 hours of sick leave annually
Nine paid holidays and 1 personal holiday each year
Opportunities for career advancement
Tuition waivers (accepted by major Florida Colleges/universities)
Student loan forgiveness opportunities (eligibility required)
Training opportunities
Flexible Spending Accounts
Shared Savings Program for select medical services
Lower copays for prescription drugs
Health and Wellness discounts