68064697 - MEDICAL/HEALTH CARE PROGRAM ANALYST

State of Florida

About The Position

This is a full-time career service position, with regularly scheduled hours of Monday-Friday 8:00 a.m. to 5:00 p.m. This Medical Health Care Program Analyst position is anticipated to be filled at a rate of $1,833.39 b/w and is non-negotiable. This position may involve travel-related activities from 1-15%. Successful completion of a criminal background investigation is a condition of employment. A good attendance record is essential for any individual in this position as the work involved occurs daily and is time sensitive. The individual in this position is expected to report to work daily and on time. The Florida Medicaid program is one of the five largest in the country and has an estimated $38 billion annual budget. Each month Florida Medicaid covers medical services for almost 4 million recipients. To most effectively serve this large patient population, one of the Agency goals is to ensure fewer budgeted dollars are lost to fraud, abuse, and waste. The Bureau of Medicaid Program Integrity (MPI) does this specifically through audits and investigations of healthcare providers, including managed care plans, suspected of engaging in fraudulent or abusive behavior, as well as overpayment recoveries, administrative sanctions, and the referral of suspected fraud or other criminal violations for law enforcement investigation. This Medical Health Care Program Analyst position will support the fraud and abuse prevention efforts within the Bureau of Medicaid Program Integrity (MPI). MPI is organized by the functions that fall within the Bureau’s responsibility: Fraud and Abuse Detection, Prevention, Overpayment Recovery, and Managed Care oversight. MPI operates with dynamic and fast-paced units that work closely with one another to serve the overall bureau mission. To address the complexity and scope of fraudulent and abusive behavior in the Florida Medicaid program, these units are responsible for developing novel methods and technologies to fight fraud, abuse, and waste. To do this, these highly collaborative and innovative units rely on teams with diverse educational and experience backgrounds. The candidate selected for this position is responsible for providing compliance oversight of the Managed Care Plans (MCPs) participating in the Statewide Medicaid Managed Care program to ensure they are meeting program integrity requirements set forth in state and federal law, as well as the provisions of contract and Medicaid policy. This selected candidate is also responsible for conducting investigations into possible fraud or abuse committed by the MCPs or their provider networks. A candidate selected for a position with an investigative unit will be responsible for conducting investigations/audits, visiting providers, identifying overpayments, writing investigative summary reports, and making recommendations for referrals to other entities involving Medicaid providers or issuing audit reports in accordance with state and federal rules, laws, and statutes. The selected candidate will be required to collaborate with other MPI operational units and regulatory agencies as well as to participate in joint data driven field initiatives and special projects. The candidate will also be responsible for utilizing open-source and proprietary resources to conduct investigations/audits and related administrative actions, as well as monitoring and tracking the associated case status. These units are seeking candidates with a broad array of knowledge and experience specifically related to fraud prevention programs, compliance assessment, and investigative and audit processes. The incumbent is responsible for conducting on-site visits to determine violations of Medicaid policies and is responsible for ensuring consistency and support regarding specific Prevention and Program Oversight (Field Operations) protocols. This position requires a broad array of knowledge and experience specifically related to fraud prevention programs, compliance assessment, legal analysis, and the investigative process as well as a desire to innovate. The selected candidate will assist in conducting investigations/audits related to fraud, abuse, and waste through research and analysis of complex health and business-related data. Included in the functions of this position are activities such as: •Utilizing open-source and proprietary resources to conduct the investigations and related administrative actions, as well as monitoring and tracking the associated case status. •Issuing audit reports or preparing referrals to law enforcement or other entities involving Medicaid providers. •Identifying, analyzing, and interpreting trends or patterns in data sets, as well as other investigative and research tools. •Assigning and deactivating user accounts and access privileges in FACTS, preparing and submitting operational, managerial, and ad-hoc reports extracted from FACTS data, and informing users of changes, trends, developments, and updates through written and verbal forms of communication and training. •Collaborating with team members on projects and assignments. •Conducting payment restriction reviews in accordance with state and federal rules, laws, and statutes. 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.

Requirements

Ability to solve problems and make decisions based on available information.
Ability to execute projects and assignments timely and accurately within a fast-paced environment.
Ability to conduct investigations, coordinate investigative activities, and accurately document the result of an investigation.
Ability to conduct fact finding research.
Ability to work independently.
Ability to communicate effectively verbally and in writing.
Ability to review and comprehend applicable federal and state laws, rules, policies, and regulations related to health care and enforcement activities.
Ability to demonstrate proficiency using Microsoft Word, Excel, Outlook, PowerPoint, SharePoint.
Ability to travel with or without accommodation.
Ability of strong research skills, written and oral communication skills, and organizational skills.
Knowledge of the Florida Medicaid Program.
Knowledge of research or investigative principles, practices, and techniques.
Two years of professional or nonprofessional experience in a regulatory or health service setting.
An associate’s degree from an accredited college or university can substitute on a year for year basis in a related field such as health law, health science, health services administration, business administration, public administration, sociology, criminology, criminal justice, or a substantially similar discipline.

Nice To Haves

Preference will be given to candidates with a program integrity related professional certification, such as: Certified Fraud Examiner; Accredited Healthcare Fraud Investigator; Certified Financial Crimes Investigator; Certified Insurance Fraud Investigator; Certified Compliance and Ethics Professional, or other relevant certification, such as: Project Management Professional.
Preference will be given to candidates with professional experience in business, or information analysis.

Responsibilities

providing compliance oversight of the Managed Care Plans (MCPs) participating in the Statewide Medicaid Managed Care program to ensure they are meeting program integrity requirements set forth in state and federal law, as well as the provisions of contract and Medicaid policy
conducting investigations into possible fraud or abuse committed by the MCPs or their provider networks
conducting investigations/audits
visiting providers
identifying overpayments
writing investigative summary reports
making recommendations for referrals to other entities involving Medicaid providers or issuing audit reports in accordance with state and federal rules, laws, and statutes
collaborating with other MPI operational units and regulatory agencies as well as to participate in joint data driven field initiatives and special projects
utilizing open-source and proprietary resources to conduct investigations/audits and related administrative actions, as well as monitoring and tracking the associated case status
conducting on-site visits to determine violations of Medicaid policies
assisting in conducting investigations/audits related to fraud, abuse, and waste through research and analysis of complex health and business-related data
Utilizing open-source and proprietary resources to conduct the investigations and related administrative actions, as well as monitoring and tracking the associated case status.
Issuing audit reports or preparing referrals to law enforcement or other entities involving Medicaid providers.
Identifying, analyzing, and interpreting trends or patterns in data sets, as well as other investigative and research tools.
Assigning and deactivating user accounts and access privileges in FACTS, preparing and submitting operational, managerial, and ad-hoc reports extracted from FACTS data, and informing users of changes, trends, developments, and updates through written and verbal forms of communication and training.
Collaborating with team members on projects and assignments.
Conducting payment restriction reviews in accordance with state and federal rules, laws, and statutes.

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