68900237 - OPS MEDICAL/HEALTH CARE PROGRAM ANALYST

State of Florida • Tallahassee, FL

5d • Onsite

About The Position

This is a full-time OPS position supporting the fraud and abuse prevention efforts within the Bureau of Medicaid Program Integrity (MPI). MPI is organized by functions including Operations, Data Detection, Investigations, Overpayment Recovery, and Managed Care oversight. MPI operates with dynamic and fast-paced units that work closely together to serve the bureau's mission. To address the complexity and scope of fraudulent and abusive behavior in the Florida Medicaid program, these units develop novel methods and technologies to fight fraud, abuse, and waste. These collaborative and innovative units rely on teams with diverse educational and experience backgrounds. The selected candidate will conduct investigations and develop fraud, waste, and abuse referrals of providers participating in the Florida Medicaid 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 involves identifying, analyzing, and interpreting trends or patterns in complex data sets and using other investigative and research tools to generate referrals to appropriate law enforcement, investigative, or regulatory agencies. It also includes prevention activities such as pre-payment reviews, paid claims reversals, site visits, and imposing payment restrictions. The candidate may conduct audits, write summary reports, and make referrals to other entities involving Medicaid providers or issue audit reports in accordance with state and federal rules, laws, and statutes. The role also involves collaborating with other MPI operational units and participating in special projects. MPI seeks candidates with broad knowledge and experience in fraud prevention programs, compliance assessment, and investigative and audit processes. This position requires knowledge 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. Activities include utilizing open-source and proprietary resources for investigations and administrative actions, monitoring case status, issuing audit reports or preparing referrals, identifying and analyzing data trends, managing user accounts and access privileges in FACTS, preparing reports from FACTS data, informing users of changes and updates, collaborating with team members, and conducting payment restriction reviews.

Requirements

• 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.
• 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.
• 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.

Nice To Haves

• 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.
• Professional experience in business or information analysis.

Responsibilities

• Conducting investigations and developing fraud, waste, and abuse referrals of providers participating in the Florida Medicaid program.
• Identifying, analyzing, and interpreting trends or patterns in complex data sets and using other investigative and research tools.
• Generating referrals to appropriate law enforcement, investigative, or regulatory agencies.
• Engaging in prevention activities, including pre-payment reviews, paid claims reversals, site visits, and imposing payment restrictions.
• Conducting audits, writing summary reports, and making referrals to other entities involving Medicaid providers or issuing audit reports.
• Collaborating with other MPI operational units and participating in special projects.
• 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 investigations and related administrative actions.
• Monitoring and tracking the associated case status.
• Issuing audit reports or preparing referrals to law enforcement or other entities involving Medicaid providers.
• Assigning and deactivating user accounts and access privileges in FACTS.
• Preparing and submitting operational, managerial, and ad-hoc reports extracted from FACTS data.
• Informing users of changes, trends, developments, and updates through written and verbal 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

• 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: Associate degree