68900289 - OPS MEDICAL/HEALTH CARE PROGRAM ANALYST

State of Florida • MIAMI, FL

5d • Onsite

About The Position

This is a full-time Other Personal Services (OPS) position with regularly scheduled hours of Monday-Friday 8:00 a.m. to 5:00 p.m. The position is anticipated to be filled at $20.00/hour and is non-negotiable. This position may involve travel-related activities from 1-15%. The Agency requires background and fingerprint screening as a condition of employment. The Florida Medicaid program is one of the five largest in the country with an estimated $38 billion annual budget, covering medical services for almost 4 million recipients monthly. The Bureau of Medicaid Program Integrity (MPI) focuses on ensuring fewer budgeted dollars are lost to fraud, abuse, and waste through audits and investigations of healthcare providers, including managed care plans, suspected of fraudulent or abusive behavior. MPI also handles overpayment recoveries, administrative sanctions, and referrals for law enforcement investigation. This Medical Health Care Program Analyst position will support these fraud and abuse prevention efforts within MPI. MPI is organized by functions: Fraud and Abuse Detection, Prevention, Overpayment Recovery, and Managed Care oversight. MPI operates with dynamic and fast-paced units that work closely to serve the bureau's mission. To address the complexity and scope of fraudulent and abusive behavior, these units develop novel methods and technologies to fight fraud, abuse, and waste, relying on teams with diverse educational and experience backgrounds. The selected candidate will provide compliance oversight of Managed Care Plans (MCPs) participating in the Statewide Medicaid Managed Care program to ensure they meet program integrity requirements set forth in state and federal law, as well as contract provisions and Medicaid policy. This role also involves conducting investigations into possible fraud or abuse committed by MCPs or their provider networks. Candidates selected for an investigative unit will conduct investigations/audits, visit providers, identify overpayments, write investigative summary reports, and make recommendations for referrals to other entities involving Medicaid providers or issue audit reports in accordance with state and federal rules, laws, and statutes. Collaboration with other MPI operational units and regulatory agencies is required, as well as participation in joint data-driven field initiatives and special projects. The candidate will utilize open-source and proprietary resources to conduct investigations/audits and related administrative actions, and monitor/track associated case status. These units seek candidates with broad knowledge and experience in fraud prevention programs, compliance assessment, and investigative and audit processes. The incumbent will conduct on-site visits to determine violations of Medicaid policies and ensure consistency and support regarding specific Prevention and Program Oversight (Field Operations) protocols. This position requires broad knowledge and experience in fraud prevention programs, compliance assessment, legal analysis, and the investigative process, along with 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.

Requirements

• Two years of investigative, enforcement, health care, or professional experience in a position within a regulatory, or oversight setting.
• 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 features including, Word, Excel, Outlook, and Edge.
• Ability to travel with or without accommodations.
• Knowledge of the Florida Medicaid Program.
• Knowledge of research or investigative principles, practices, and techniques.
• Possess investigative skills, research skills, written and oral communication skills, and organizational skills.

Nice To Haves

• Bachelor's degree or higher from an accredited college or university, particularly in a related field such as: health law, health science, criminology, criminal justice, or a substantially similar discipline.
• 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.

Responsibilities

• Utilizing open-source and proprietary resources to conduct 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.
• 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.
• 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, and making recommendations for referrals to other entities involving Medicaid providers or issuing audit reports.
• Collaborating with other MPI operational units and regulatory agencies.
• Participating in joint data driven field initiatives and special projects.
• Conducting on-site visits to determine violations of Medicaid policies.
• Ensuring consistency and support regarding specific Prevention and Program Oversight (Field Operations) protocols.
• Assisting in conducting investigations/audits related to fraud, abuse, and waste through research and analysis of complex health and business-related data.

Benefits

• No state income tax for residents of Florida
• State Group Insurance coverage options (must meet eligibility requirements), including health, life, dental, vision, and other supplemental insurance options
• Savings & Spending Accounts
• 401 (a) FICA Alternative Plan administered through VALIC (tax deferred Retirement Savings Plan)
• Participation in the Florida Deferred Compensation Plan (457b)

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed