Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid Agency, is driven by the passion to deliver comprehensive and cost effective health care to Arizonans in need. AHCCCS is nationally acclaimed as a model for other Medicaid programs and recipient of multiple awards for excellence in workplace effectiveness and flexibility.
All Arizona state employees operate within the Arizona Management System (AMS), an intentional, results-driven approach for doing the work of state government whereby every employee reflects on performance, reduces waste, and commits to continuous improvement with sustainable progress. Through AMS, every state employee seeks to understand customer needs, identify problems, improve processes, and measure results. State employees are highly engaged, collaborative and embrace a culture of public service. Visit our careers page to learn more about AHCCCS. Use your skills to benefit others; join the AHCCCS Team!
The Office of Inspector General is looking for a highly motivated individual to join our team as a Data/Medical Investigator. The purpose of this position is to uphold the integrity of the Medicaid program through data analysis, ad hoc claim/encounter reports, case evaluations, audits, investigations, and an assortment of program integrity projects. Major duties and responsibilities include but are not limited to:
* Perform detailed research and data analysis of encounter and claims information gathered from data mining, the AHCCCS mainframe and Lexis Nexis. Maintain thorough and detailed case notes for each investigation. Respond to intelligence information requests that include case evaluations, self-audits, ad-hoc reports, data samplings, audits and inter-agency requests for information.
* Perform medical record reviews, CPT coding analysis, and handle provider appeals and health plan issues related to audit recoveries; and conduct ancillary investigations as well as investigations as required based on the needs of the Program Integrity Team.
* Develop and prepare complex spreadsheets and graphs indicating over payments, misuse of funding and aberrant billings identified through the audit process and data analytic activities. Maintain and update shared team spreadsheets accurately.
* Identify the civil and/or criminal components of a case, and when appropriate present the criminal evidence to law enforcement for prosecution. Follow rules of evidence in maintaining documents, retention and disposition.
* Coordinate with various AHCCCS divisions, AHCCCS providers, health plans, other state agencies, and licensing boards to uphold the integrity of the Medicaid program.
* Conduct interviews and obtain written statements from AHCCCS providers to determine if fraudulent activities have occurred. Authority to draft and serve subpoenas and take sworn statements. Prepare written reports for use in administrative or legal proceedings.
* Attend meetings, participate in discussion topics, and prepare and present program integrity material for process improvement.
KNOWLEDGE, SKILLS AND ABILITIES (KSAs):
* Knowledge Of: Claims and encounter processing, HIPAA, CPT coding, medical records, Microsoft Office (especially Excel), Arizona revised statutes, Medicaid and Medicare fraud, waste and abuse statutes, investigative techniques.
* Skilled in: Data analytics, investigative methods, program compliance auditing, preparation of detailed spreadsheets, medical record analysis, problem solving, application of appropriate laws, regulations and policies, written and verbal communication, research analysis, team oriented.
* Ability to: Analyze healthcare data for fraud, waste and abuse. Prepare reports in a clear and concise manner. Drive a state vehicle. Conduct a logical investigation as necessary.
* Two or more years of healthcare data analytics. Certified Fraud Examiner (CFE), or Certified Professional Coder (CPC) or other related certification.
At AHCCCS, we promote the importance of work/life balance by offering workplace flexibility and a variety of learning and career development opportunities. Among the many benefits of a career with the State of Arizona, there are 10 paid holidays per year, accrual of sick and annual leave, affordable medical benefits and participation in the Arizona State Retirement Plan. Click here to learn more about benefits.
Arizona State Government is an EOE/ADA Reasonable Accommodation Employer. Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by calling (602) 417-4678. Requests should be made as early as possible to allow sufficient time to arrange the accommodation. AHCCCS is an Equal Employment Opportunity Employer. All newly hired employees will be subject to E-Verify Employment Eligibility Verification.
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Please apply for this position by following the link provided below. A new window will open on your screen and you will be directed to the Arizona Health Care Cost Containment System (AHCCCS) employment website.