Business Operations Analyst (HCA/MAD #9144)

New Mexico Department of Justice; Santa Fe (NM); On-site; USD 52,000 - 78,000; Full time

Job summary

The Business Operations Analyst will support the integrity of New Mexico's Medicaid program by reviewing allegations of provider fraud, waste, and abuse, conducting initial reviews, and coordinating with MCOs and partner agencies to ensure timely disposition and recovery of improper payments.

Document referrals, maintain confidential records, and communicate professionally with internal and external partners while adhering to privacy rules.

Qualifications

• Analytical mindset for evaluating claims, financial, health care, or compliance information.
• Ability to conduct research and document findings clearly.
• Strong written and verbal communication skills.
• Experience collaborating with internal staff, MCOs, providers, and investigative partners.
• Knowledge of Medicaid, health care billing, fraud, waste and abuse, program integrity or auditing is desirable.

Responsibilities

• Receive and evaluate allegations of Medicaid provider fraud, waste, and abuse from MCOs, state agencies, providers, members and other sources.
• Conduct initial reviews and research using claims systems and supporting documentation.
• Request additional information as needed and determine referrals.
• Document, assign, and track referrals and cases in program integrity systems; keep records complete and confidential.
• Coordinate referrals with MCOs and investigative or oversight entities; monitor through final resolution.
• Assist with Medicaid claims reviews, audits, and projects to identify overpayments and vulnerabilities.
• Support corrective actions and recovery of improper Medicaid payments per federal and state requirements.
• Communicate professionally while maintaining HIPAA compliance.

Skills

Analytical skills

Attention to detail

Organizational skills

Written communication

Verbal communication

Collaboration

Medicaid knowledge

Education

High school diploma

Tools

Medicaid claims systems

Case-tracking systems

Job description

Job Title Business Operations Analyst (HCA/MAD #9144)

For more Job Requirements & Classification Description:

Interviews are anticipated to be conducted within two weeks of closing date.

This job posting may be used to fill multiple vacancies.

The Health Care Authority (HCA) participates in E-Verify and will verify employment eligibility upon hire.

Our Vision

• Every New Mexican has access to affordable health care coverage through a coordinated and seamless health care system.

Our Mission

• We ensure that New Mexicans attain their highest level of health by providing whole-person, cost-effective, accessible, and high-quality health care and safety-net services.

Our Goals

• Leverage purchasing power and partnerships to create innovative policies and models of comprehensive health care coverage that improve the health and well-being of New Mexicans and the workforce.
• Achieve health equity by addressing poverty, discrimination, and lack of resources, building a New Mexico where everyone thrives.
• Implement innovative technology and data-driven decision-making to provide unparalleled, convenient access to services and information.
• Build the best team in state government by supporting employees continuous growth and wellness.

Why does the job exist?

The Business Operations Analyst will:

• Support the integrity of New Mexico's Medicaid program by receiving and reviewing allegations of provider fraud, waste, and abuse;
• Conduct initial reviews and preliminary investigations determining the appropriate disposition and referring matters to the appropriate investigative or oversight entity;
• Document and track referrals through final resolution;
• Coordinate with Managed Care Organizations (MCO) and partner agencies and participates in claims reviews, audits, and other Program Integrity activities to identify overpayments and program vulnerabilities and support the recovery of Medicaid funds.

How does it get done?

The Business Operations Analyst is responsible for:

• Receiving and evaluating allegations of Medicaid provider fraud, waste, and abuse from Managed Care Organizations (MCO), state agencies, providers, members, and other sources;
• Conducting initial reviews and preliminary research using Medicaid claims systems, provider records, supporting documentation, and available data to assess each allegation;
• Requesting additional information or investigative work when necessary and recommending the appropriate referral disposition;
• Documenting, assigning, and tracking referrals and cases in Program Integrity systems, ensuring records remain complete, accurate, current, and confidential;
• Coordinating referrals with MCO's and appropriate investigative or oversight entities and monitoring matters through final resolution;
• Assisting with Medicaid claims reviews, audits, and special projects to identify overpayments, billing concerns, and program vulnerabilities;
• Supporting corrective actions and the recovery of improper Medicaid payments in accordance with federal and state requirements;
• Communicating professionally with internal and external partners while maintaining HIPAA compliance and protecting sensitive information.

Who are the customers?

• New Mexico Medicaid members, providers and Managed Care Organizations (MCO);
• Health Care Authority (HCA) staff and leadership;
• State and federal investigative and oversight partners.

Ideal Candidate

The Ideal Candidate has:

• Analytical, detail-oriented, organizational skills and is able to manage multiple referrals and deadlines with limited supervision;
• Experience reviewing claims, financial, health care, or compliance-related information;
• Experience conducting research, identifying inconsistencies or potential concerns and clearly documenting findings;
• Strong written and verbal communication skills, sound judgment, problem-solving ability, and experience working with databases or case-tracking systems;
• Ability to collaborate effectively with internal staff, Managed Care Organizations (MCO), providers, and investigative or oversight partners while maintaining confidentiality and handling sensitive information appropriately;
• Knowledge of Medicaid, health care billing, fraud, waste and abuse, program integrity, auditing, or regulatory compliance is highly desirable.

High School diploma or Equivalency and two (2) years of experience in office administration, budgeting, purchasing, finance, accounting, auditing, cash management, contract management, and/or the procedures of business and management principles involved in strategic planning. Any combination of education from an accredited college or university in a related field and/or direct experience in this occupation totaling two (2) years may substitute for the required experience.

Employment Requirements

Must possess and maintain a valid Driver's License. Must obtain a Defensive Driving Certification.

Working Conditions

Work is performed in an office setting with exposure to Visual/Video Display Terminal (VDT) and extensive personal computer and phone usage with extended periods of sitting. Some standing, bending and reaching may be required.

Supplemental Information

For information on Statutory Requirements for this position.

Bargaining Unit Position

This position is covered by a collective bargaining agreement and all terms/conditions of that agreement apply and must be adhered to.