Job Summary :
This position conducts complex criminal and civil investigations relating to allegations of Medicaid eligibility fraud. In depth research investigative report writing, researching Medicaid eligibility rules, policies, statutes. Prepare documentation for Civil and Criminal Prosecution.
Major duties and responsibilities include but are not limited to :
- Conducts in depth investigations that include field investigations, surveillance, interviewing and interrogating subjects or witnesses in their home or agency's office.
- Compiles, analyzes, organizes, Medicaid eligibility records, financial records and other related documents; Composes detailed reports of investigations to submit to prosecuting agencies for criminal prosecution and / or administrative action.
- Conducts investigative Internet searches, uses and interprets other investigative sources such as : ACJIS, Experian Credit Reports, CLEAR, Lexis Nexis, Vital Records, AZ Corp Commission, NWSC, AZ MVD reports, Etc.
- Collects, Examines, and preserves information, documents and records for evidence
- Interprets applicable, federal and state laws, agency rules, regulations and policy regarding Medicaid eligibility and criminal violations
- Serves Subpoena's to obtain necessary evidence to prove or disprove allegations of Medicaid fraud
- Participates in special projects that may include out of town travel involving residency / eligibility checks of participants as well as on-site audits of certain high risk Medicaid providers. Must be willing to travel overnight if necessary.
- Other duties as assigned as related to the position (typically 5% - 10%)
Knowledge, Skills & Abilities (KSAs) :
Knowledge :
Criminal, civil and administrative law, Federal Medicaid / Medicare statutes, rules and regulations as they relate to Title 19, 16, & 21 United States CodeArizona Revised Statutes, titles 13 and 36, Computerized AHCCCS and the Arizona Department of Economic Security (DES) mainframe systems to effectively extract relevant informationVarious types of eligibility programs including but not limited to; Social Security Disability, Long Term Care program, Supplemental Security Income, Temporary Assistance to Needy Families (TANF) program, and the Sixth Omnibus Budget Reconciliation Act (SOBRA)Income and resource requirements for eligibility for each of these varied programsPreparation of detailed computerized spreadsheets to show how the fraud and accompanying loss of funds to the program was perpetrated, State Personnel Rules when state employees may be the subject of an investigationAHCCCS divisions, the services they provide and how they interact with other divisionsPrinciples of accounting practices and audit techniquesSkills :
Legal decisions as they relate to the admissibility of evidence, confessions, admissions and statementsProper methods of interviewing suspects, witnesses and victims, and of the rules regarding the admissibility of statements, admissions and confessionsEffective methods to conduct a covert operation to identify fraudulent activityInvestigative methods, techniques, and approaches, necessary to plan and conduct criminal, civil and administrative investigations relating to the operations and activities of AHCCCS, conflict resolutionAbilities :
Interpreting and applying Federal and State Statutes and Agency policiesConduct investigations, Manage time effectively, deal with difficult situations in a calm manorEffectively handle hostile situationsDrive a State vehicleSuccessfully function in a virtual office environmentQualifications : Minimum :
At least two years' experience as an Auditor or equivalent or Bachelor’s Degree in Accounting, Healthcare, Criminal Justice or related field.Preferred :
CPC, CFE Certification, or Medical or Health Care financial background, or 4 yrs of eligibility experience, or a 4 year degree from accredited university in a closely related field. Knowledge of : Proper methods of interviewing suspects, witnesses and victims, and of the rules regarding the admissibility of statements, admissions and confessions, and Title 19, ASRS 13 and 36.Pre-Employment Requirements :
Successfully complete the Electronic Employment Eligibility Verification Program (E-Verify), applicable to all newly hired State employees.Successfully pass fingerprint background check, prior employment verifications and reference checks; employment is contingent upon completion of the above-mentioned process and the agency’s ability to reasonably accommodate any restrictions.Travel may be required for State business. Employees who drive on state business must complete any required driver training (see Arizona Administrative Code R2-10-207.12.) AND have an acceptable driving record for the last 39 months including no DUI, suspension or revocations and less than 8 points on your license. If an Out of State Driver License was held within the last 39 months, a copy of your MVR (Motor Vehicle Record) is required prior to driving for State Business. Employees may be required to use their own transportation as well as maintaining valid motor vehicle insurance and current Arizona vehicle registration; however, mileage will be reimbursed.If this position requires driving or the use of a vehicle as an essential function of the job to conduct State business, then the following requirements apply : Driver’s License Requirements.
All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).
Benefits :
Among the many benefits of a career with the State of Arizona, there are :
10 paid holidays per yearPaid Vacation and Sick time off (13 and 12 days per year respectively) - start earning it your 1st day (prorated for part-time employees)Paid Parental Leave-Up to 12 weeks per year paid leave for newborn or newly-placed foster / adopted child (pilot program).Other Leaves - Bereavement, civic duty, and military.A top-ranked retirement program with lifetime pension benefitsA robust and affordable insurance plan, including medical, dental, life, and disability insuranceParticipation eligibility in the Public Service Loan Forgiveness Program (must meet qualifications)RideShare and Public Transit SubsidyA variety of learning and career development opportunitiesBy providing the option of a full-time or part-time remote work schedule, employees enjoy improved work / life balance, report higher job satisfaction, and are more productive. Remote work is a management option and not an employee entitlement or right. An agency may terminate a remote work agreement at its discretion.
Learn more about the Paid Parental Leave pilot program here.
