MEDICAL/HEALTH CARE PROGRAM ANALYST - 43005185

Requisition No: 856503 

Agency: Financial Services

Working Title: MEDICAL/HEALTH CARE PROGRAM ANALYST - 43005185

 Pay Plan: Career Service

Position Number: 43005185 

Salary:  $46,668.00 - $99,779.40 

Posting Closing Date: 07/28/2025 

Total Compensation Estimator Tool

 *****OPEN COMPETITIVE EMPLOYMENT OPPORTUNITY*****

DIVISION: WORKERS’ COMPENSATION

BUREAU: MONITORING AND AUDIT

CITY: TALLAHASSEE

COUNTY: LEON

SPECIAL NOTES:

Four (4) years of equivalent work experience in a relevant field (medical billing, insurance, claims handling, or business) is required. A post-secondary degree may be used as an alternative for the years of experience on a year-for-year basis.

Preferences:

• One (1) year of experience in medical billing, medical bill review or medical data analysis.
• One (1) year of experience using Microsoft Office Applications (Word, Excel, and Outlook).
• Experience being deposed or testifying in court.
• One (1) year of workers’ compensation experience.
• Experience understanding and applying applicable rules, regulations, policies and procedures pertaining to a health services program.

This position requires a security background check, including fingerprint as a condition of employment.

We anticipate hiring for an additional position (43005186 - Medical/Health Care Program Analyst) from this advertisement.

Employees of the Department of Financial Services are paid on a monthly pay cycle.

Responses to qualifying questions must be clearly supported by the state application and any omission, falsification, or misrepresentation in the answering of the qualifying questions will be cause for immediate elimination from the selection process.

Minimum Qualifications for this position include the following REQUIRED ENTRY LEVEL KNOWLEDGE, SKILLS AND ABILITIES:

Ability to direct and coordinate the planning and implementation of operational and program reviews and program monitoring activities. Ability to utilize problem-solving techniques. Ability to understand and apply applicable rules, regulations, policies and procedures pertaining to a health services program. Ability to prioritize workload. Ability to develop various reports. Ability to design, develop and implement research models. Ability to manage a health services program. Ability to assess budgetary needs. Ability to collect and analyze financial data. Ability to formulate policies and procedures. Ability to plan, organize and coordinate work activities. Ability to communicate effectively. Ability to establish and maintain effective working relationships with others.

BRIEF DESCRIPTION OF DUTIES:

This is complex work analyzing, reviewing and/or monitoring reimbursement dispute petitions to resolve contested reimbursement for medical services billed to insurance companies and reimbursement and utilization disputes between health care providers and carriers, under the authority of s. 440.13(7), F.S. and rule 59A-31, F.A.C.  This position exercises independent judgment in the application of statutes and relevant administrative rules governing eligibility for reimbursement and reimbursement methodology and requires extensive knowledge of laws, statutes and rules throughout the State of Florida.   

Documents case status in the Automated Rehabilitation and Medical Information Services (ARAMIS) system to reflect actions taken, correspondence issued, and final outcome for each assigned petition, including timely completion of the Case tab, Parties Involved tab, Reimbursement Dispute tab, Docket tab and the Journal.  Keeps abreast of process changes relevant to documentation in ARAMIS as internal operating procedures are amended to improve the documentation system.

Reviews reimbursement dispute petitions to resolve contested reimbursement for medical services billed to insurance companies and resolves reimbursement and utilization disputes between health care providers and carriers, under the authority of s. 440.13(7), F.S. and rule 59A-31, F.A.C., utilizing applicable schedules of maximum reimbursement allowances developed pursuant to s. 440.13(12), F.S.  Consults with Registered Nurse Consultant as necessary to identify issues that may be relevant to Determinations and to obtain guidance as to how to address these issues. This includes drafting detailed formal Determination and case Dismissal documents explaining the rationale for the Agency’s decision, based on the applicable rules and exhibits of other documentation provided by the parties, as they apply.  Testifies in court to defend the rational used to reach decisions in the issued determinations.

Manages case load of disputes assigned on a rotation system to ensure that affected parties are provided Notices of Deficiency timely, and that Agency Determinations and Dismissals are issued within 60 days of receipt of all documentation as required by statute.  Ensures that personal work products are accurate as to form and content relating to legal entities identified, statutory or regulatory citations, calculations or tabulations, grammar and referenced attachments, and consistent with Agency policy.

Examines Explanation of Bill Reviews (EOBRs) submitted with reimbursement disputes for proper code usage and compliance with the Billing Rules.  Research carrier trends and identifies deficiencies.  Document findings of these studies and prepares recommendations for the implementation of Division training or audit referral.  Analyzes data gathered in ARAMIS and compare it to Florida’s variations in coding with national averages and creates reports outlining cost/reimbursement differences. Uses data mining and outliers to identify improper payments.

Monitors and tracks dispute outcomes and identifies trends related to inappropriate reimbursements.  Works directly with carrier (or entity acting on behalf of carrier) on underpayments to ensure compliance with the applicable statutory and regulatory requirements, to include the use of the appropriate fee schedule. 

Plans and conducts special studies of problems and procedures. Assists with annual or special reports, surveys and ad hoc studies, as needed or as required, by the Three Member Panel.  Performs other related duties as required.

If you are a retiree of the Florida Retirement System (FRS), please check with the FRS on how your current benefits will be affected if you are re-employed with the State of Florida. Your current retirement benefits may be canceled, suspended, or deemed ineligible depending upon the date of your retirement.

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.