68048395 - GOVERNMENT OPERATIONS CONSULTANT II

Requisition No: 835812 

Agency: Agency for Health Care Administration

Working Title: 68048395 - GOVERNMENT OPERATIONS CONSULTANT II

 Pay Plan: Career Service

Position Number: 68048395 

Salary:  $1,694.62 - $2,203.01 Biweekly 

Posting Closing Date: 11/21/2024 

Total Compensation Estimator Tool

Agency Overview:

The Agency for Health Care Administration (AHCA) is Florida's chief health policy and planning entity.

The Agency is responsible for administering the Florida Medicaid program, the licensure and regulation of nearly 50,000 health care facilities, and empowering consumers through health care transparency initiatives.

Under the direction of the Agency Secretary, AHCA is focused on advancing Governor DeSantis’ vision for Florida’s health care system to be the most cost-effective, transparent, and high-quality health care system in the nation.

The Medicaid program provides low-income families and individuals with access to health care. 

If you have a desire to use your talent and skills at an organization that provides critical services to millions of individuals and families across the state, AHCA invites you to apply to become an essential member of our team.

As one of Florida’s leading state agencies, AHCA’s diverse workforce community of more than 1,400 employees is proud of its efforts to serve the people of Florida.

Agency Objectives:

HIGH QUALITY

Emphasizing quality in all that we do to improve health outcomes, always putting the individual first.

TRANSPARENT

Supporting initiatives that promote transparency and empower consumers in making well informed healthcare decisions.

COST-EFFECTIVE

Leveraging Florida’s buying power in delivering high quality care at the lowest cost to taxpayers.

Position Overview:

This is an exciting opportunity to help shape the quality of health care in Florida.

We are seeking to hire a Government Operations Consultant II who desires to work to enhance the delivery of health care services through the Florida Medicaid Program. 

This position requires a candidate who is creative, flexible, innovative, and who will thrive in a fast-paced, team based work environment.

This position is located in the Bureau of Medicaid Plan Management Operations (PMO).

PMO is responsible for the primary oversight of Medicaid’s managed care programs, with a focus on the Statewide Medicaid Managed Care (SMMC) program.

The bureau’s primary responsibility is ensuring that the managed care plans meet Medicaid contractual requirements, including the timely provision of medically needed services and provider payment for such services.

This position is responsible for reviewing Medicaid managed care claim complaints and determining managed care compliance with the SMMC contract as it relates to claims processing. 

Examples of work include:

Analyzes programmatic reports of claims and provider reimbursement issues/complaints to determine managed care plan compliance with contract provisions.

Coordinates and performs monitoring of Medicaid Managed Care Plan claim submission protocols and standard claim processing procedures through the review of claim complaints, claim forms, explanation of benefits, and authorizations in order to make a compliance determination.

Follows established unit policies and procedures to ensure the compliance process is conducted in a consistent manner and reviews findings to ensure they are documented appropriately.

Analyzes compliance issues and makes recommendations for compliance actions when issues are identified in the managed care plan provider reimbursement and claims processes.

Conducts program training to Medicaid managed care plans related to compliance with contract provisions, provider reimbursement and claims processing requirements.

Maintains up-to-date knowledge concerning the Florida Medicaid Program.

Participates in meetings, prepares and delivers speeches with the Agency, with managed care organizations and other stakeholders.

Represent Medicaid on health care related committees, task forces, and special projects, as assigned.

This position may require travel.  

This position is not a remote or telework position; it will have to report to a Field Office or the Headquarters in Tallahassee.

Benefits of Working for the State of Florida:

Working for the State of Florida is more than a paycheck. The State’s total compensation package for employees features a highly competitive set of employee benefits including:

• State Group Insurance Coverage Options, including health, life, dental, vision, and other supplemental insurance options;

• Flexible Spending Accounts;

• State of Florida retirement options, including employer contributions;

• Generous annual and sick leave benefits;

• 9 paid holidays a year and 1 Personal Holiday each year;

• Career advancement opportunities;

• Tuition waiver for courses offered by Florida’s nationally ranked State University System;

• Training and professional development opportunities;

• And more!

For more information about the Bureau of Plan Management Operations, please visit our website at http://ahca.myflorida.com/Medicaid/index.shtml.

Join us at the Agency for Health Care Administration in fulfilling our mission to provide “Better Health Care for all Floridians.”    

KNOWLEDGE, SKILLS, AND ABILITIES

Knowledge of Medicaid eligibility, programs, policies, and benefit limitations.

Knowledge of medical claims processing and/or health insurance claims billing.

Knowledge of the methods of data collection and analysis.

Knowledge of and ability to effectively utilize computer skills such as Microsoft Office 2016 (Word, Excel, Outlook).

Knowledge of the techniques used in compiling and analyzing data.

Ability to collect, evaluate and analyze data to develop alternative recommendations, solve problems, document workflow and other activities related to the improvement of operations.

Ability to organize data in a logical format for presentation in reports, documents and other written materials.

Ability to conduct fact-finding research.

Ability to utilize problem-solving techniques.

Ability to work independently.

Ability to understand and apply applicable rules, regulations, policies and procedures relating to operational activities.

Ability to make decisions in a timely manner.

Ability to verify accuracy of data.

Ability to establish and maintain effective working relationships with all levels of staff.

Possesses effective verbal and written communication skills.

Ability to travel with or without accommodations.

MINIMUM QUALIFICATIONS REQUIREMENTS

At least 2 years of medical claims billing experience or 2 years medical claims processing experience with the understanding of the Explanation of Payment and Explanation of Benefit Statements for health insurance companies/government healthcare related programs.

At least 2 years of experience researching and interpreting policies and procedures.

At least 2 years of experience using computers and various software programs such as Outlook, Word and Excel.

At least 1 year experience auditing or conducting monitoring of medical claims activities related to a healthcare program. 

PREFERRED:

A Bachelor’s Degree or degree in a healthcare field from an accredited college or university is preferred.  Professional or non-professional experience as described above can substitute on a year-for-year basis for the preferred college education.

LICENSURE, CERTIFICATION, OR REGISTRATION REQUIREMENTS

N/A

CONTACT:  EDWARD WEISER 954-958-6513

BACKGROUND SCREENING

It is the policy of the Florida Agency for Health Care Administration that any applicant being considered for employment must successfully complete a State and National criminal history check as a condition of employment before beginning employment, and, if applicable, also be screened in accordance with the requirements of Chapter 435, F.S., and Chapter 408, F.S.  No applicant may begin employment until the background screening results are received, reviewed for any disqualifying offenses, and approved by the Agency.  Background screening shall include, but not be limited to, fingerprinting for State and Federal criminal records checks through the Florida Department of Law Enforcement (FDLE) and Federal Bureau of Investigation (FBI) and may include local criminal history checks through local law enforcement agencies.

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.