Non Par Provider Registration Analyst

Job Summary:
The Non Par Provider Registration Analyst is responsible to perform in depth research, analysis, evaluation and eligibility of Non Par Provider Registrations to detect potential fraudulent activity against Florida Blue and Government contracts. Coordinate findings with Special Investigation Unit (SIU) case investigators and SIU management to determine case creation or escalation.

Essential Job Functions:

• Perform in depth research, analysis, evaluation and eligibility of Non Par Provider Registrations to detect potential fraudulent activity against Florida Blue and Government contracts. Utilize internal guidelines, agency guidelines, as well as State and Federal regulations. Reviews claims history, provider files, etc. and utilizes data analytics techniques to detect irregularities. Conducts telephone interviews with Non Par providers and/or provider staff to determine validity of Non Par registration application. Initiates onsite provider inspections with external business partners. Works with internal business partners to update provider profiles and complete deactivation/reactivation of Non Par providers.

• Document, track and report Non Par Provider Registration findings. Prepare necessary documents and communications to providers as well as internal and external business partners. Coordinate findings with Special Investigation Unit (SIU) case investigators and SIU management to determine case creation or escalation. Maintains confidentiality of all sensitive information and secure PHI as required by law and regulations.

• Participates in team projects, major investigations/cases as needed.

• Acts as a mentor and provides education and training to team members.

Job Requirements:

• Bachelor’s degree in Accounting, Criminology, Business or other related field or equivalent work experience.
• Working knowledge of medical review, auditing, and/or internal controls.
• Working knowledge of Florida Blue systems/platforms, medical costs, claims, and enrollment
• Working knowledge of Microsoft office to include Excel, Word, PowerPoint, SharePoint
• Basic working knowledge of statistics and data analysis techniques.
• Excellent oral and written communication skills and an ability to communicate effectively with all levels of the organization.
• Demonstrated ability to handle multiple and conflicting priorities
• Detail-oriented
• Ability to work with minimal supervision

Preferred Criteria:

• Bachelor’s degree in Accounting, Criminology, Business or other related field or equivalent work experience.
2+ years related experience in healthcare fraud investigations or a related field.
• Working knowledge of CPT, ICD-10 and HCPCS codes

Required Competencies:

• Teamwork & Collaboration
• Building Relationships
• Continuous Improvement
• Demonstrates flexibility and supports change