Salary: $70000 - $80000

FLSA Status: Exempt

Grade: 24

This position will remain open until filled.

This position is responsible for the development of program integrity operational oversight for healthcare fraud waste and abuse. This position will implement and interpret policies procedures standards and methods for the Provider Compliance Section. Complete and supervise required health care fraud audits and investigations to establish if program violations have occurred through billing or other acts related to fraud waste and abuse performance of special crossover projects as assigned.

Major duties and responsibilities include but are not limited to:
Complete and supervise required health care fraud audits and investigations to establish if program violations have occurred through billing health care records financial documentation access to mainframe computer systems at AHCCCS DES MVD and DPS and other evidentiary documentation. Receives and tracks complaints makes assignments and supervises staff activities.
Reviews and approves all case reports. Serves as the final quality control review to ensure that all technical and reporting standards are met. Refers completed case reports as appropriate to the Attorney General and federal law enforcement agencies.
Develop and review overpayments; losses to the Medicaid Program through diligent research and review in order to present the evidence to the legal authorities for prosecution. Communicates effectively with public and internal staff both orally and in writing.
Attends meetings with senior management to provide case updates to discuss overpayment civil monetary penalty recommendations adverse actions settlement offers and to discuss policy issues related to the Provider Fraud Unit Reviews national literature and best practices attends professional conferences and recommends ways to more effectively control fraud and abuse in the AHCCCS program
Conduct and supervise investigations during the Audit and or Investigative process. Review written statements taken by investigators from providers and clients to determine if fraudulent activities have occurred.
Interpret understand and analyze information concerning medically oriented programs management information data auditing/statistical data and Medicaid (AHCCCS) services. Conduct and supervise investigators during the Audit and or Investigative process.

Knowledge:
Knowledge and experience working with MCO and AHCCCS Fee For Service and American Indian Health Plan policy and guidelines
Criminal civil and administrative law Federal Medicaid/Medicare statutes rules and regulations as they relate to Title 19 16 & 21 Non Title 19 United States Code
Arizona Revised Statutes titles 13 and 36 Arizona Administrative Codes
Claim processing procedures financing contracts and operation of Managed Care Organizations (MCOs) and Fee For Service/Tribal ALTCS populations understanding of the AIHP program and populations
Computerized AHCCCS and the Arizona Department of Economic Security (DES) mainframe systems to effectively extract relevant information
Preparation 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 investigation
AHCCCS divisions the services they provide and how they interact with other divisions
Principles of accounting practices and audit techniques

Skills:
Government process experience related to: Auditing process improvement and investigation standards
Medicaid/Medicare AIHP Fee For Service reviews healthcare knowledge Investigations or behavioral health
Legal decisions as they relate to the admissibility of evidence confessions admissions and statements maintenance of evidence and precision following established departmental protocols
Proper methods of interviewing suspects witnesses and victims and of the rules regarding the admissibility of statements admissions and confessions
Effective methods to conduct a covert operation to identify fraudulent activity
Investigative methods techniques and approaches necessary to plan and conduct criminal civil and administrative investigations relating to the operations and activities of AHCCCS
Time management conflict resolution and management

Abilities:
Manage time effectively deal with difficult situations in a calm manner
Supervise effectively while carrying a case load
Effectively handle hostile situations analyze interpret and communicate data
Communicate effectively both verbally and in writing conduct performance audits testify in State and/or Federal courts
Interact with Management at a high level providing guidance when necessary
Provide information in both written and verbal briefs to Management as needed
Operate a State Vehicle and at times conduct field work to support an investigation

Arizona Drivers License.

Minimum:
Two years experience as an Auditor or closely related field.

Two or more years showing increased workflow responsibilities.

Preferred:
Two or more years experience providing direct supervision and overseeing daily activities of a section (or) Degree in Criminal Justice or related field or Certified Fraud Examiner (CFE) Certification or Certified Professional Coder (CPC) and two or more years of responsible investigative experience preferably in government healthcare law enforcement insurance or managed care organization.

Successfully pass fingerprint background check prior employment verifications and reference checks; employment is contingent upon completion of the above-mentioned process and the agencys 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 R.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:Drivers License Requirements.

All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).

Among the many benefits of a career with the State of Arizona there are:
10 paid holidays per year
Paid 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. Learn more about the Paid Parental Leave pilot program here.
Other Leaves - Bereavement civic duty and military.
A top-ranked retirement program with lifetime pension benefits
A robust and affordable insurance plan including medical dental life and disability insurance
Participation eligibility in the Public Service Loan Forgiveness Program (must meet qualifications)
RideShare and Public Transit Subsidy
A variety of learning and career development opportunities

By 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 programhere. For a complete list of benefits provided by The State of Arizona please visit our benefits page

Lifetime Pension Benefit Program
Administered through the Arizona State Retirement System (ASRS)
Defined benefit plan that provides for life-long income upon retirement.
Required participation for Long-Term Disability (LTD) and ASRS Retirement plan.
Pre-taxed payroll contributions begin after a 27-week waiting period (prior contributions may waive the waiting period).

Deferred Retirement Compensation Program
Voluntary participation.
Program administered through Nationwide.
Tax-deferred retirement investments through payroll deductions.

Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by emailing .

Requests should be made as early as possible to allow time to arrange the accommodation. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer.