HEALTH INSURANCE FRAUD ANALYST II - 72004150

Requisition No: 859230 

Agency: Management Services

Working Title: HEALTH INSURANCE FRAUD ANALYST II - 72004150

 Pay Plan: Career Service

Position Number: 72004150 

Salary:  $59,000 - $62,000 

Posting Closing Date: 09/02/2025 

Total Compensation Estimator Tool

Health Insurance Fraud Analyst II
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 a Health Insurance Fraud Analyst II 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 incumbent 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.
•    Provides investigative support to the Program Integrity Unit.
•    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.
•    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. 

 

 

Other Duties:
Performs additional duties and projects assigned by management and provides cross-functional support to other DSGI work units for special projects and peak workload periods as required to support the Division’s operational needs. Provides prompt, professional and courteous customer service in response to all inquiries and requests for information received by DSGI.

 

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.
•    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 in