Job Description

Requisition No: 872921

Agency: Agency for Health Care Administration

Working Title: 68900289 - OPS MEDICAL/HEALTH CARE PROGRAM ANALYST

Pay Plan: Temp

Position Number: 68900289

Salary: $20.00 Hourly

Posting Closing Date: 04/09/2026

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This is a full-time OPS position, with regularly scheduled hours of Monday-Friday 8:00 a.m. to 5 p.m.

The OPS Medical Health Care Program Analyst position is anticipated to be filled at $20.00 /hour and is non-negotiable.

This position may involve travel related activities from 1-15%.

*The Agency requires background and fingerprint screening as a condition of employment.

The Florida Medicaid program is one of the five largest in the country and has an estimated $38 billion annual budget.

Each month Florida Medicaid covers medical services for almost 4 million recipients.

To most effectively serve this large patient population, one of the Agency goals is to ensure fewer budgeted dollars are lost to fraud, abuse, and waste.

The Bureau of Medicaid Program Integrity (MPI) does this specifically through audits and investigations of healthcare providers, including managed care plans, suspected of engaging in fraudulent or abusive behavior, as well as overpayment recoveries, administrative sanctions, and the referral of suspected fraud or other criminal violations for law enforcement investigation.

This Medical Health Care Program Analyst position will support the fraud and abuse prevention efforts within the Bureau of Medicaid Program Integrity (MPI).

MPI is organized by the functions that fall within the Bureau’s responsibility: Fraud and Abuse Detection, Prevention, Overpayment Recovery, and Managed Care oversight.

MPI operates with dynamic and fast-paced units that work closely with one another to serve the overall bureau mission.

To address the complexity and scope of fraudulent and abusive behavior in the Florida Medicaid program, these units are responsible for developing novel methods and technologies to fight fraud, abuse, and waste.

To do this, these highly collaborative and innovative units rely on teams with diverse educational and experience backgrounds.

The candidate selected for this position is responsible for providing compliance oversight of the Managed Care Plans (MCPs) participating in the Statewide Medicaid Managed Care program to ensure they are meeting program integrity requirements set forth in state and federal law, as well as the provisions of contract and Medicaid policy.

This selected candidate is also responsible for conducting investigations into possible fraud or abuse committed by the MCPs or their provider networks.

A candidate selected for a position with an investigative unit will be responsible for conducting investigations/audits, visiting providers, identifying overpayments, writing investigative summary reports, and making recommendations for referrals to other entities involving Medicaid providers or issuing audit reports in accordance with state and federal rules, laws, and statutes.

The selected candidate will be required to collaborate with other MPI operational units and regulatory agencies as well as to participate in joint data driven field initiatives and special projects.

The candidate will also be responsible for utilizing open-source and proprietary resources to conduct investigations/audits and related administrative actions, as well as monitoring and tracking the associated case status.

These units are seeking candidates with a broad array of knowledge and experience specifically related to fraud prevention programs, compliance assessment, and investigative and audit processes.

The incumbent is responsible for conducting on-site visits to determine violations of Medicaid policies and is responsible for ensuring consistency and support regarding specific Prevention and Program Oversight (Field Operations) protocols.

This position requires a broad array of knowledge and experience specifically related to fraud prevention programs, compliance assessment, legal analysis, and the investigative process as well as a desire to innovate.

The selected candidate will assist in conducting investigations/audits related to fraud, abuse, and waste through research and analysis of complex health and business-related data. Included in the functions of this position are activities such as:

•Utilizing open-source and proprietary resources to conduct the investigations and related administrative actions, as well as monitoring and tracking the associated case status.

•Issuing audit reports or preparing referrals to law enforcement or other entities involving Medicaid providers.

•Identifying, analyzing, and interpreting trends or patterns in data sets, as well as other investigative and research tools.

•Assigning and deactivating user accounts and access privileges in FACTS, preparing and submitting operational, managerial, and ad-hoc reports extracted from FACTS data, and informing users of changes, trends, developments, and updates through written and verbal forms of communication and training.

•Collaborating with team members on projects and assignments.

•Conducting payment restriction reviews in accordance with state and federal rules, laws, and statutes.

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 Other Personal Services (OPS) employees features a highly competitive set of employee benefits including:

• No state income tax for residents of Florida;

• State Group Insurance coverage options (must meet eligibility requirements), including health, life, dental, vision, and other supplemental insurance options;

• Savings & Spending Accounts;

• 401 (a) FICA Alternative Plan administered through VALIC (tax deferred Retirement Savings Plan);

• Participation in the Florida Deferred Compensation Plan (457b)

For a more complete list of benefits and eligibility requirements, visit www.mybenefits.myflorida.com.

What is OPS employment?

OPS employment is a temporary employer/employee relationship used for accomplishing short term or intermittent tasks. OPS employees are at-will employees and are subject to actions such as pay changes, changes to work assignment, and terminations at the pleasure of the agency head or designee.

OPS employees do not serve probationary periods or become permanent in their positions because they serve at the pleasure of the agency head

KNOWLEDGE, SKILLS, AND ABILITIES

•Ability to solve problems and make decisions based on available information.

•Ability to execute projects and assignments timely and accurately within a fast-paced environment.

•Ability to conduct investigations, coordinate investigative activities, and accurately document the result of an investigation.

•Ability to conduct fact finding research.

•Ability to work independently.

•Ability to communicate effectively verbally and in writing.

•Ability to review and comprehend applicable federal and state laws, rules, policies, and regulations related to health care and enforcement activities.

•Ability to demonstrate proficiency using Microsoft features including, Word, Excel, Outlook, and Edge.

•Ability to travel with or without accommodations.

•Knowledge of the Florida Medicaid Program.

•Knowledge of research or investigative principles, practices, and techniques.

•Possess investigative skills, research skills, written and oral communication skills, and organizational skills.

MINIMUM QUALIFICATIONS REQUIREMENTS

Two years of investigative, enforcement, health care, or professional experience in a position within a regulatory, or oversight setting.

Preference will be given to candidates with a bachelor's degree or higher from an accredited college or university, particularly in a related field such as: health law, health science, criminology, criminal justice, or a substantially similar discipline.

Preference will be given to candidates with a program integrity related professional certification, such as: Certified Fraud Examiner; Accredited Healthcare Fraud Investigator; Certified Financial Crimes Investigator; Certified Insurance Fraud Investigator; or Certified Compliance and Ethics Professional.

LICENSURE, CERTIFICATION, OR REGISTRATION REQUIREMENTS

N/A

CONTACT: HELEN GUNN 850-412-4626

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.

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.