Behavioral Health Program Integrity Analyst

Position Summary: The Behavioral Health Program Integrity Analyst is responsible for conducting reviews of Medicaid service justifications, documentation concerns, and other atypical billing matters. This position supports CFBHN's oversight responsibilities by identifying potential compliance issues, billing irregularities, documentation deficiencies, and patterns that may indicate program integrity concerns. The analyst works collaboratively with network service providers, CFBHN staff, and state partners to promote accurate billing, appropriate service authorization practices, and compliance with Medicaid and contractual requirements.

This position performs analytical and investigative activities but does not provide clinical services, make medical necessity determinations, or require professional licensure.

This is a temporary full-time position created to support an important organizational initiative and is expected to continue for up to two (2) years. The position offers the opportunity to make a meaningful impact while receiving competitive compensation, benefits, and paid time off, subject to organizational policies and benefit plan eligibility requirements. As organizational needs evolve, CFBHN may modify, extend, or conclude the assignment.

Qualifications

Required Education/Experience

• Master’s degree in healthcare administration, public administration, business administration, accounting, finance, behavioral healthcare, or related field.
• Three years of experience in healthcare compliance, Medicaid administration, utilization management, auditing, claims review, provider oversight, billing compliance, or related work.
• Experience reviewing complex records, data, documentation, or financial information and identifying irregularities.
• Strong analytical, organizational, and written communication skills.
• Proficiency with Microsoft Excel, One Drive, SharePoint, Artificial Intelligence tools, and database applications.
• Licensure as LCSW, LMFT or LMHC

Preferred Qualifications

• Experience with Florida Medicaid behavioral health services.
• Experience working with managed care organizations, managing entities, health plans, or healthcare provider organizations.
• Experience conducting audits, investigations, or compliance reviews.
• Certification related to compliance, fraud examination, auditing, healthcare quality, or investigations (e.g., CHC, CHPC, CFE, CPC, CHA).

 

Essential Job Functions

• Review Medicaid service justifications and supporting documentation submitted by network service providers.
• Analyze atypical billing patterns, utilization concerns, and provider documentation issues referred through UM processes.
• Conduct detailed reviews of service records, claims-related documentation, and authorization materials to determine compliance with contractual, Medicaid, and state requirements.
• Identify trends, patterns, and potential areas of concern related to billing practices, service documentation, and provider compliance.
• Prepare written findings, summaries, recommendations, and technical assistance communications.
• Coordinate with Utilization Management, Quality Management, Compliance, Provider Relations, and Contract Management staff regarding identified concerns.
• Assist in the development of monitoring tools, audit protocols, and risk-based review processes.
• Track investigations, referrals, corrective actions, and follow-up activities.
• Participate in provider education efforts related to documentation standards, billing requirements, and program integrity expectations.
• Maintain confidentiality of protected health information and sensitive investigative information.
• Support audits, state reviews, and internal monitoring activities as assigned.
• Perform other related duties as assigned.
• Knowledge of healthcare compliance and Medicaid program requirements.
• Ability to evaluate documentation and data, then able to identify inconsistencies, trends, and potential compliance concerns.
• Ability to conduct fact-based reviews and prepare objective written findings.
• Ability to interpret policies, contracts, regulations, and billing requirements.
• Ability to communicate effectively with provider organizations and internal stakeholders.
• Ability to maintain discretion and handle sensitive information appropriately.
• Strong critical thinking and investigative skills.