68900289 - OPS MEDICAL/HEALTH CARE PROGRAM ANALYST

State of Florida

31d • Onsite

About The Position

This is a full-time OPS position, with regularly scheduled hours of Monday-Friday 8:00 a.m. to 5 p.m. The OPS Medical Health Care Program Analyst 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 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.

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 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
• Two years of investigative, enforcement, health care, or professional experience in a position within a regulatory, or oversight setting

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

• 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
• Participating 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
• 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
• 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
• 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

• 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: Entry Level
• Education Level: No Education Listed