68048394 - GOVERNMENT OPERATIONS CONSULTANT II

Agency Overview The Agency for Health Care Administration (AHCA) is Florida's chief health policy and planning entity. It administers the Florida Medicaid program, oversees licensure and regulation of nearly 50,000 health care facilities, and empowers consumers through health care transparency initiatives. Under the direction of the Agency Secretary, AHCA works to make Florida’s health care system the most cost-effective, transparent, and high-quality system in the nation. Agency Objectives HIGH QUALITY – Emphasizing quality in all that we do to improve health outcomes, always putting the individual first. TRANSPARENT – Supporting initiatives that promote transparency and empower consumers to make well‑informed healthcare decisions. COST‑EFFECTIVE – Leveraging Florida’s buying power to deliver high‑quality care at the lowest cost to taxpayers. Position Overview We are seeking a Government Operations Consultant II who is creative, flexible, innovative, and thrives in a fast‑paced, team‑based work environment. This role enhances the delivery of health care services through the Florida Medicaid Program and involves reviewing Medicaid managed care claim complaints and determining managed care compliance with the SMMC contract as it relates to claims processing. Key Responsibilities Analyze programmatic reports of claims and provider reimbursement issues/complaints to determine managed care plan compliance with contract provisions. Coordinate and perform monitoring of Medicaid Managed Care Plan claim submission protocols and standard claim processing procedures by reviewing claim complaints, claim forms, explanation of benefits, and authorizations to make a compliance determination. Follow established unit policies and procedures to ensure the compliance process is conducted consistently and reviews findings for proper documentation. Analyze compliance issues and make recommendations for compliance actions when issues are identified in the managed care plan provider reimbursement and claims processes. Conduct program training for Medicaid managed care plans on compliance with contract provisions, provider reimbursement, and claims processing requirements. Maintain up‑to‑date knowledge of the Florida Medicaid Program. Participate in meetings, prepare and deliver speeches with the Agency, managed care organizations, and other stakeholders. Represent Medicaid on health care related committees, task forces, and special projects as assigned. Travel may be required; this position is not remote or teleworking. Benefits of Working for the State of Florida Health insurance (individual and family coverage) Life insurance; $25,000 policy free plus option to purchase additional life insurance Dental, vision, and supplemental insurance State of Florida retirement options, including employer contributions Earn up to 104 hours of paid annual leave as a new employee Earn up to 104 hours of sick leave annually Nine paid holidays and one personal holiday each year Opportunities for career advancement Tuition waivers (accepted by major Florida Colleges/universities) Student loan forgiveness opportunities (eligibility required) Training opportunities Flexible Spending Accounts Shared Savings Program for select medical services Lower copays for prescription drugs Health and Wellness discounts Position Details Pay Plan: Career Service Position Number: 68048394 Salary: $1,864.08 – $2,203.01 Biweekly Posting Closing Date: 06/03/2026 Knowledge, Skills, And Abilities Knowledge of Medicaid eligibility, programs, policies, and benefit limitations Knowledge of medical claims processing and/or health insurance claims billing Knowledge of methods of data collection and analysis Knowledge and effective use of computer skills such as Microsoft Office 2016 (Word, Excel, Outlook) Ability to collect, evaluate, and analyze data to develop alternative recommendations, solve problems, document workflow, and other activities related to operations improvement Ability to organize data logically for presentation in reports, documents, and other written materials Ability to conduct fact‑finding research, utilize problem‑solving techniques, and work independently Understand and apply applicable rules, regulations, policies, and procedures related to operational activities Make timely decisions, verify accuracy of data, and establish effective working relationships with all staff levels Effective verbal and written communication skills Ability to travel with or without accommodation Minimum Qualifications Requirements Two (2) years of experience in medical claims billing or processing with the understanding of Explanation of Payment and Explanation of Benefit Statements for health insurance companies or government healthcare programs Two (2) years of experience researching and interpreting policies and procedures Two (2) years of experience using Microsoft Office and related software programs One (1) year experience auditing or conducting monitoring of medical claims activities related to a healthcare program Licensure, Certification, Or Registration Requirements None Contact Edward Weiser – View phone number on click.appcast.io Background Screening The Florida Agency for Health Care Administration requires a State and National criminal history check, including federal, state, and local criminal record checks, before employment begins. Background screening must be completed and approved before employment starts. Equal Opportunity / Non‑Discrimination The State of Florida is an Equal Opportunity Employer/Affirmative Action Employer and does not tolerate discrimination or violence in the workplace. 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. Veterans must provide supporting documentation, including DD Form 214, by the close of the vacancy announcement. Legal Disclaimers Benefits information is subject to change. For a complete list of benefits, visit . For more information about the Bureau of Plan Management Operations, visit . #J-18808-Ljbffr CareersElite.com