68064693 - MEDICAL HEALTH CARE PROGRAM ANALYST

State of Florida•Tallahassee, FL

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 identifying, investigating, and supporting the prevention of fraud, waste, and abuse with a primary focus on Durable Medical Equipment and Supplies (DME). The position conducts complex claim analysis, performs targeted provider clinical and compliance reviews of records, evaluates compliance with Medicaid policy, state rules and laws, federal regulations, and maintains ongoing knowledge of emerging trends, policies, rules, laws, and federal regulations relevant to program integrity, and DME providers and services. The selected candidate will also represent the Agency as a subject matter expert during administrative hearings. The selected candidate may be responsible for conducting investigations/audits to identify aberrant billing patterns, improper utilization, and potential fraud or abuse within DME claims, writing summary reports, and making 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 also be responsible for working collaboratively with other MPI operational units and participating in special projects, compliance site visits, and inspections. The candidate will also be responsible for utilizing open-source and proprietary resources to conduct the audits, investigations and related administrative actions, as well as monitoring and tracking the associated case status. This position requires a broad array of knowledge and experience specifically related to fraud prevention programs, compliance assessment, case management, 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 records. Included in the functions of this position are activities such as: • Conducting desk or onsite records reviews to determine documentation sufficiency, and compliance with Medicaid provisions, state laws and rules, and federal regulations. • Developing findings and recommendations for overpayment recoveries, assessing sanctions, and making referrals to law enforcement partners. • Interpreting claims in the context of clinical standards, policy requirements, and expected utilization patterns. •Identifying deficiencies, patterns of noncompliance, and opportunities for provider education or corrective action. • In collaboration with agency counsel, preparing testimony, exhibits, and expert statements that articulate clinical rationale, policy interpretation, and audit or investigative findings. • Collaborating with team members on projects and assignments. • Providing internal consultation and training on claim decisions, rules and guidelines, and issues related to program integrity of DME providers and services.

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 coding certification, such as Certified Professional Coder, Certified Coding Specialist, Certified Professional Biller, Certified Professional Medical Auditor or other relevant equivalent.
Preference will be given to candidates with respiratory therapy, occupational therapy, physical therapy, nursing, or durable medical equipment and supply setting experience.

Responsibilities

Identifying, investigating, and supporting the prevention of fraud, waste, and abuse with a primary focus on Durable Medical Equipment and Supplies (DME)
Conducting complex claim analysis
Performing targeted provider clinical and compliance reviews of records
Evaluating compliance with Medicaid policy, state rules and laws, federal regulations, and maintains ongoing knowledge of emerging trends, policies, rules, laws, and federal regulations relevant to program integrity, and DME providers and services
Representing the Agency as a subject matter expert during administrative hearings
Conducting investigations/audits to identify aberrant billing patterns, improper utilization, and potential fraud or abuse within DME claims
Writing summary reports, and making referrals to other entities involving Medicaid providers or issuing audit reports in accordance with state and federal rules, laws, and statutes
Working collaboratively with other MPI operational units and participating in special projects, compliance site visits, and inspections
Utilizing open-source and proprietary resources to conduct the audits, investigations and related administrative actions, as well as monitoring and tracking the associated case status
Conducting desk or onsite records reviews to determine documentation sufficiency, and compliance with Medicaid provisions, state laws and rules, and federal regulations
Developing findings and recommendations for overpayment recoveries, assessing sanctions, and making referrals to law enforcement partners
Interpreting claims in the context of clinical standards, policy requirements, and expected utilization patterns
Identifying deficiencies, patterns of noncompliance, and opportunities for provider education or corrective action
In collaboration with agency counsel, preparing testimony, exhibits, and expert statements that articulate clinical rationale, policy interpretation, and audit or investigative findings
Collaborating with team members on projects and assignments
Providing internal consultation and training on claim decisions, rules and guidelines, and issues related to program integrity of DME providers and services

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