HEALTH INSURANCE FRAUD ANALYST III - 72004151

Requisition No: 856383 

Agency: Management Services

Working Title: HEALTH INSURANCE FRAUD ANALYST III - 72004151

 Pay Plan: Career Service

Position Number: 72004151 

Salary:  $64,000.00 - $66,000.00 

Posting Closing Date: 07/24/2025 

Total Compensation Estimator Tool

Health Insurance Fraud Analyst III
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 candidate will join the Division of State Group Insurance, Program Integrity Unit as a Health Insurance Fraud Analyst III and will be responsible for utilizing a broad scope of data analytics to proactively identify qualified leads for potential fraud, waste, and abuse (FWA) investigations. The selected candidate will be accountable to conduct data mining to identify outliers and trends based on relevant FWA topics; design and implement algorithms to effectively data-mine within various types of claims data utilizing a variety of software applications; compile research, data analyses, and final results into comprehensive reports for bureau investigations. This position requires a high degree of confidentiality, accuracy, and adherence to deadlines.

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

• Identify suspicious patterns in 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.
• Build queries in support of PIU operations and the maintenance of data integrity for PIU systems and processes.
• Extract and summarize data from a variety of sources, including but not limited to claims platforms, data warehouse and other applicable databases within the organization.
• Attending and participating in PIU-related meetings and required training.

Knowledge, Skills, and Abilities:

• Experience in medical coding/billing and/or the processing of medical claims.
• Experience in working in healthcare system or similar professional medical environment.
• 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.
• Possesses 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. Post-secondary education in the field(s) of criminology, healthcare administration, nursing, 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 medical coding, billing, compliance, prevention, fraud detection, or investigation of fraud, waste or abuse in health care or experience in auditing, data collection/analysis, and management.
• Experience with SQL, SAS Enterprise Guide (EG), R, and 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:
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.”

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.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.