HEALTH CARE SYSTEMS ANALYST - 72004076

Health Care Systems Analyst - 72004076

The selected candidate will join the Division of State Group Insurance, Program Integrity Unit as an Audit Manager and will serve as an auditor and contract manager for the state group insurance program's post payment claims audits and the Pharmacy Benefits Manager compliance audit. This position is essential to managing all audit activities within the division, and ensuring that state funds are accounted for, reported, and monitored in accordance with contract requirements, and state and federal laws. The incumbent must be knowledgeable and experienced in auditing and monitoring, financial and claims data analysis, data collection methods, generally accepted accounting principles, and government auditing standards. This position is critical to identifying organizational fraud, waste and abuse risks and developing recommendations to mitigate those risks.

Specific responsibilities for this position will include, but not be limited to, the following :

• Manages and coordinates audits performed by external consultants of all insurance vendors contracted by the Department offering insurance benefits under the State Employees' Group Insurance Program.
• Recommends and monitors insurance vendors' corrective action plans until deficiencies are cured and issues are resolved.
• Manages the post payment claims audit contract, serves as the Division's liaison with the contracted vendor and tracks, monitors, and documents vendor's performance.
• Manages the Pharmacy Benefits Manager compliance audit contract, serves as the Division's liaison with the contracted vendor and tracks, monitors, and documents vendor's performance.
• Performs monthly reconciliation of overpayment recoveries and assisting with the preparation of detailed audit reports.
• Receives, validates, and approves monthly invoices for processing.
• Analyzes quarterly performance guarantee reporting and assesses appropriate liquidated damages as required by contract.
• Develops procurement documents to select external audit consultants.
• Performs data analytics to identify fraud, waste, or abuse in claims data.
• Organizes data and prepares a written summary of investigative steps, conclusions, recommendations with attention to detail and a high level of accuracy.
• Prepares clear and concise investigatory reports to support findings of potential fraud, waste and abuse.
• Prepares statistical / financial analysis reports and graphic presentation for notification of findings.
• Presents case to internal department(s), law enforcement and / or regulatory agencies.
• Supports legal proceedings as needed, including testifying in court, or working with law enforcement personnel to prepare cases for civil or criminal actions.
• Develops and maintains general knowledge of health care reimbursement policies related to health care fraud and abuse.
• Works cooperatively and constructively with team members.
• Maintains security and confidentiality of all protected health information encountered in performance of duties

Other duties include performing additional duties and projects assigned by management and providing cross-functional support to other DSGI work units for special projects and peak workload periods as required to support the Division's operational needs. Provides prompt, professional and courteous customer service in response to all inquiries and requests for information received by DSGI.

Knowledge, skills, and abilities include experience in auditing, data analysis, or fraud detection; strong working knowledge of generally accepted audit standards; experience collecting and analyzing data and information; ability to analyze and interpret data; strong analytical and problem-solving abilities; strong organizational skills; ability to effectively manage vendor relationships; ability to effectively and efficiently work both independently and as a contributing member of a team; excellent written and verbal communication skills; ability to plan, organize and coordinate work assignments so that deadlines are met; advanced proficiency in Microsoft Office Suite and Power BI; knowledgeable of health care coding conventions, fraud schemes, general areas of vulnerability, reimbursement methodologies and relevant laws to find suspicious patterns in claims data and other sources; experience generating, interacting with and interpreting pivot tables of varying complexity; ability to use independent judgment to create investigative work plans and develop case strategies based upon analysis.

Minimum qualifications include four years of experience in a related field such as healthcare, finance, accounting, business or risk management, or a substantially similar discipline. Post-secondary education may be used as an alternative for years of experience on a year-for-year basis. Two years of professional work experience in healthcare and billing compliance, auditing, data collection / analysis and management are required. Demonstrable contract auditing and monitoring experience is required. Proficiency in Microsoft Office, Word, and Excel is required.

Under the direction of Governor Ron DeSantis, Secretary Pedro Allende and DMS' Executive Leadership Team, the Florida Department of Management Services (DMS) is a customer-oriented agency with a broad portfolio that includes the efficient use and management of real estate, procurement, human resources, group insurance, retirement, telecommunications, fleet, and federal property assistance programs used throughout Florida's state government. It is against this backdrop that DMS strives to demonstrate its motto, "We serve those who serve Florida."

DMS is committed to successfully recruiting and onboarding talented and skilled individuals into its workforce. We recognize the extensive training, experience, and transferrable skills that veterans and individuals with disabilities bring to the workforce. Veterans and individuals with disabilities are encouraged to contact our recruiter for guidance and answers to questions through the following provided email addresses : DMS.Ability@dms.fl.gov DMS.Veterans@dms.fl.gov An individual with a disability is qualified if he or she satisfies the skills, experience, and other job related requirements for a position and can perform the essential functions of the position with or without reasonable accommodation. Candidates requiring a reasonable accommodation, as defined by the Americans with Disabilities Act, must contact the DMS Human Resources (HR) Office at (850) 488-2707. DMS requests applicants notify HR in advance to allow sufficient time to provide the accommodation. Successful completion of background screening will be required for this position. The State of Florida is an Equal Opportunity Employer / Affirmative Action Employer, and does not tolerate discrimination or violence in the workplace.

Candidates requiring a reasonable accommodation, as defined by the Americans with Disabilities Act, must notify the agency hiring authority and / or People First Service Center (1-866-663-4735). Notification to the hiring authority must be made in advance to allow sufficient time to provide the accommodation.

The State of Florida supports a Drug-Free workplace. All employees are subject to reasonable suspicion drug testing in accordance with Section 112.0455, F.S., Drug-Free Workplace Act.

VETERANS' PREFERENCE. Pursuant to Chapter 295, Florida Statutes, candidates eligible for Veterans' Preference will receive preference in employment for Career Service vacancies and are encouraged to apply. Certain service members may be eligible to receive waivers for postsecondary educational requirements. Candidates claiming Veterans' Preference must attach supporting documentation with each submission that includes character of service (for example, DD Form 214 Member Copy #4) along with any other documentation as required by Rule 55A-7, Florida Administrative Code. Veterans' Preference documentation requirements are available by clicking here . All documentation is due by the close of the vacancy announcement.