68048394 - GOVERNMENT OPERATIONS CONSULTANT II

State of Florida•Fort Lauderdale, FL

43d•Onsite

About The Position

The Agency for Health Care Administration (AHCA) is Florida's chief health policy and planning entity, responsible for administering the Florida Medicaid program, the licensure and regulation of nearly 50,000 health care facilities, and empowering consumers through health care transparency initiatives. Under the direction of the Agency Secretary, AHCA is focused on advancing Governor DeSantis’ vision for Florida’s health care system to be the most cost-effective, transparent, and high-quality health care system in the nation. The Medicaid program provides low-income families and individuals with access to health care. AHCA invites you to apply to become an essential member of their team, serving the people of Florida. The agency's objectives include emphasizing quality to improve health outcomes, supporting initiatives that promote transparency, and leveraging Florida’s buying power in delivering high quality care at the lowest cost to taxpayers. This Government Operations Consultant II position offers an exciting opportunity to help shape the quality of health care in Florida by enhancing the delivery of health care services through the Florida Medicaid Program. This role requires a creative, flexible, innovative candidate who will thrive in a fast-paced, team-based work environment. The position is responsible for reviewing Medicaid managed care claim complaints and determining managed care compliance with the SMMC contract as it relates to claims processing.

Requirements

Knowledge of Medicaid eligibility, programs, policies, and benefit limitations.
Knowledge of medical claims processing and/or health insurance claims billing.
Knowledge of the methods of data collection and analysis.
Knowledge of and ability to effectively utilize computer skills such as Microsoft Office 2016 (Word, Excel, Outlook).
Knowledge of the techniques used in compiling and analyzing data.
Ability to collect, evaluate and analyze data to develop alternative recommendations, solve problems, document workflow and other activities related to the improvement of operations.
Ability to organize data in a logical format for presentation in reports, documents and other written materials.
Ability to conduct fact-finding research.
Ability to utilize problem-solving techniques.
Ability to work independently.
Ability to understand and apply applicable rules, regulations, policies and procedures relating to operational activities.
Ability to make decisions in a timely manner.
Ability to verify accuracy of data.
Ability to establish and maintain effective working relationships with all levels of staff.
Possesses effective verbal and written communication skills.
Ability to travel with or without accommodation.
Two (2) years of experience in medical claims billing or medical claims processing with the understanding of the Explanation of Payment and Explanation of Benefit Statements for health insurance companies/government healthcare related programs.
Two (2) years of experience researching and interpreting policies and procedures.
Two (2) years of experience using Microsoft Office (Outlook, Word, Excel, etc.) and various software programs.
One (1) year experience auditing or conducting monitoring of medical claims activities related to a healthcare program.

Responsibilities

Analyzes programmatic reports of claims and provider reimbursement issues/complaints to determine managed care plan compliance with contract provisions.
Coordinates and performs monitoring of Medicaid Managed Care Plan claim submission protocols and standard claim processing procedures through the review of claim complaints, claim forms, explanation of benefits, and authorizations to make a compliance determination.
Follows established unit policies and procedures to ensure the compliance process is conducted in a consistent manner and reviews findings to ensure they are documented appropriately.
Analyzes compliance issues and makes recommendations for compliance actions when issues are identified in the managed care plan provider reimbursement and claims processes.
Conducts program training to Medicaid managed care plans related to compliance with contract provisions, provider reimbursement and claims processing requirements.
Maintains up-to-date knowledge concerning the Florida Medicaid Program.
Participates in meetings, prepares and delivers speeches with the Agency, with managed care organizations and other stakeholders.
Represent Medicaid on health care related committees, task forces, and special projects, as assigned.

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 104 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