HEALTH INSURANCE FRAUD ANALYST - 72004151

Requisition No: 826110 

Agency: Management Services

Working Title: HEALTH INSURANCE FRAUD ANALYST - 72004151

 Pay Plan: Career Service

Position Number: 72004151 

Salary:  $65,000.00 - $75,000.00 

Posting Closing Date: 04/30/2024 

Total Compensation Estimator Tool

Health Insurance Fraud Analyst

Division of State Group Insurance

State of Florida Department of Management Services

This position is located in Tallahassee, FL

Position Overview and Responsibilities:

The selected candidates will join the Division of State Group Insurance, Program Integrity Unit as Health Insurance Fraud Analysts and will perform data mining and investigative activities to identify fraud, waste, or abuse in claims data within our program. Additionally, these positions will provide analytical and consultative support related to data integrity and quality within our program.  

Through data exploration, the Health Insurance Fraud Analysts will identify outliers and trends based on relevant fraud, waste, and abuse topics; design and implement algorithms to effectively data-mine within various types of claims data utilizing a variety of software applications; compile research, data analysis, and results into comprehensive reports for unit investigations. Specific responsibilities of this position will include, but not be limited to, the following:
 

• Identify suspicious patterns within claims data and other sources by applying your knowledge of heath care coding conventions, fraud schemes, general areas of vulnerability, reimbursement methodologies and relevant laws.
• In collaboration with the team and the Program Integrity Unit Manager, draft investigative work plans and develop case strategies based upon analysis.
• Organize data and prepare a written summary of investigative steps, conclusions, recommendations.
• Prepare clear and concise investigatory reports and statistical/financial analysis to support findings of potential fraud, waste, and abuse.
• Present case to agency leadership, law enforcement and/or regulatory agencies.
• Utilize a variety of complex applications, tools, and processes to successfully work within and between very large data sets.
• Proactively identify new and emerging medical & pharmacy fraud schemes through research and use of the various software applications.
• Work with the team to design data analysis strategies to identify potential areas for a focused investigation.
• Support legal proceedings as needed, including testifying in court or working with law enforcement personnel to prepare cases for civil or criminal actions.

Knowledge, Skills, and Abilities:

• Experience in auditing, data analysis, or fraud detection.
• Knowledge of claims processing and medical terminology.
• Experience in creating, supporting, or writing reports, business correspondence and   technical documents.
• Experience using Healthcare-related software applications including data quality.
• Experience in quality assurance, and or investigations.
• Ability to multi-task and complete multiple project assignments simultaneously.
• Demonstrates exemplary organizational and prioritization skills.
• Strong analytical and problem-solving skills.
• Displays a high level of initiative and is action oriented.
• Careful attention to detail and accuracy in work products; critical thinking and intellectual curiosity.
• Ability to work independently with self-initiative and limited direction yet be collaborative and team minded.
• Ability to extract data of multiple formats, analyze, and document results.
• Ability to work with a variety of stakeholders in sometimes difficult situations while maintaining professionalism.
• Advanced Excel skills required plus in-depth knowledge and proficiency with MS Power BI or similar software. 

Minimum Qualifications:

• Four years of professional work experience related to the duties and responsibilities outlined above. Postsecondary education in the field(s) of criminology, healthcare administration, accounting, risk management, or similar discipline may be used as an alternative for years of experience on a year-for-year basis. 
• Two years of professional work experience in a position with duties related to the prevention, detection, or investigation of fraud, waste or abuse in health care or experience in auditing, data analysis, or fraud detection.
• Experience with SQL, SAS Enterprise Guide (EG), R, and/or Excel.

Preferred Qualifications:

Industry certifications, e.g., Certified Fraud Examiner; Accredited Healthcare Fraud Investigator; Certified Financial Crimes Investigator; Certified Insurance Fraud Investigator, Certified Compliance and Ethics Professional.

Our Organization and Mission:

The Department of Management Servies (DMS) is a customer-oriented agency responsible for managing the various business and workforce-related functions of state government. Under the direction of Governor Ron DeSantis and DMS’ Executive Leadership Team, the agency oversees the real estate, procurement, human resources, group insurance, retirement, technology, telecommunications, private prisons, fleet, and federal property assistance programs utilized throughout Florida’s state government. It is against this backdrop that DMS strives to demonstrate its mission, “We serve those who serve Florida.” Under the leadership of DMS Secretary Pedro Allende, DMS’ employees embody four pillars on a daily basis: lead by example, serve with excellence, create efficiencies, and challenge the status quo.

Special Notes:
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.myflorida.com
DMS.Veterans@dms.myflorida.com
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.