68900289 - OPS MEDICAL/HEALTH CARE PROGRAM ANALYST

State of Florida • MIAMI, FL

42d

About The Position

The Medical/Health Care Program Analyst supports fraud and abuse prevention efforts in the Florida Agency for Health Care Administration’s Bureau of Medicaid Program Integrity (MPI). The role provides compliance oversight of Managed Care Plans participating in the Statewide Medicaid Managed Care program, ensuring they meet state and federal program integrity requirements, contract provisions, and Medicaid policy. It also investigates possible fraud or abuse involving managed care plans or their provider networks.

The position assists with investigations and audits involving fraud, abuse, and waste through research and analysis of complex health and business data. Work may include visiting providers, identifying overpayments, issuing audit reports, preparing referrals to law enforcement or other entities, and making recommendations. The role collaborates with MPI operational units and regulatory agencies, participates in joint data-driven field initiatives and special projects, and uses open-source and proprietary resources to support investigations and administrative actions. The analyst monitors case status and conducts on-site visits to identify Medicaid policy violations, supporting consistency with Prevention and Program Oversight (Field Operations) protocols.

The position also supports operational and administrative functions, including managing FACTS user accounts and access privileges, producing operational, managerial, and ad hoc reports from FACTS data, communicating updates and trends to users, and conducting payment restriction reviews. The role is full-time OPS employment, scheduled Monday through Friday, 8:00 a.m. to 5:00 p.m., with anticipated pay of $20.00 per hour. Travel-related activities may account for 1–15% of the work. Employment is contingent on required background and fingerprint screening.

Requirements

• At least two years of investigative, enforcement, health care, or professional experience in a regulatory or oversight setting.
• Ability to solve problems and make decisions based on available information.
• Ability to execute projects and assignments accurately and on time in a fast-paced environment.
• Ability to conduct investigations, coordinate investigative activities, and accurately document investigation results.
• Ability to conduct fact-finding research and work independently.
• Effective verbal and written communication skills.
• Ability to review and understand applicable federal and state laws, rules, policies, and regulations related to health care and enforcement activities.
• Proficiency with Microsoft 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.
• Investigative, research, written and oral communication, and organizational skills.
• Successful completion and approval of required state and national criminal history and fingerprint screening before beginning employment.

Nice To Haves

• Bachelor’s degree or higher from an accredited college or university, particularly in 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

• Provide compliance oversight of Managed Care Plans participating in the Statewide Medicaid Managed Care program.
• Investigate possible fraud or abuse by Managed Care Plans or their provider networks.
• Assist with investigations and audits related to Medicaid fraud, abuse, and waste through research and analysis of complex health and business data.
• Conduct investigations and audits, visit providers, identify overpayments, write investigative summary reports, and make recommendations for referrals or issue audit reports.
• Collaborate with MPI operational units, regulatory agencies, team members, and others on joint initiatives, projects, and assignments.
• Use open-source and proprietary resources to conduct investigations and related administrative actions, and monitor and track case status.
• Conduct on-site visits to identify violations of Medicaid policies and support consistent application of Field Operations protocols.
• Identify, analyze, and interpret trends or patterns in data sets and use investigative and research tools.
• Assign and deactivate FACTS user accounts and access privileges.
• Prepare and submit operational, managerial, and ad hoc reports extracted from FACTS data.
• Communicate changes, trends, developments, and updates to users in writing and verbally, including through training.
• Conduct payment restriction reviews in accordance with applicable state and federal rules, laws, and statutes.

Benefits

• No state income tax for Florida residents.
• State Group Insurance coverage options, subject to eligibility, including health, life, dental, vision, and supplemental insurance.
• Savings and 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