Arizona Health Care Cost Containment System
Accountability, Community, Innovation, Leadership, Passion, Quality, Respect, Teamwork
Medical Compliance Auditor
Apply by: 11/11/2019
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 Medical Compliance Auditor. This position is directly involved in negotiating the final determination of financial over-payments and recommending civil monetary penalties levied against providers participating in fraudulent billing practices. The information obtained by this position is used for a variety of activities such as: determination of fines, restitution and cost avoidance; internal deliberation's regarding settlement amounts for fines and restitution, participate in the decisions regarding opening and closing of criminal and civil investigations. Major duties and responsibilities include but are not limited to:
* Complete required health care fraud audits regarding provider allegations, establish if program violations have occurred through billing, health care records, financial documentation, access to mainframe computer systems to include, but not limited to AHCCCS, DES, MVD and DPS.
* Research Policy, Contracts, Laws, Procedures and other documentation as it relates to health care fraud allegations.
* Develop over-payment reports: losses to the Medicaid Program through diligent research and review.
* Communicate effectively with AHCCCS providers, and contractors occasionally under adverse arid threatening circumstances. Authority to draft and serve subpoenas and take sworn statements.
* Conduct interviews and obtain written statements from AHCCCS providers, and clients to determine if fraudulent activities have occurred.
* Prepare written reports for use in administrative or legal proceedings.
* Participate in Arizona Management Systems (AMS) and Lean.
KNOWLEDGE, SKILLS AND ABILITIES (KSAs):
* Thorough knowledge of HIPAA and the rules pertaining to the sharing of investigative information, Relevant statutes and laws pertaining to the investigation of Medicaid fraud, waste and abuse, Medical claims processing, procedures, financing and operations for Fee For Service and Managed Care Organizations.
* Knowledge of income and resource requirements for eligibility for each of Medicare/Medicaid programs, Arizona Revised Statutes, State Personnel Rules. Medical coding and billing practices.
* Ability to prepare written documentation in a clear and concise manner, to learn compliance as it relates to Healthcare, AHCCCS Providers, and AHCCCS member safety.
* Skilled in: computing, summarizing, and aggregating qualitative and quantitative data in an accurate and timely manner, techniques and approaches necessary to plan and conduct program compliance audits.
* Skilled in interpreting and applying federal and state laws, rules, regulations, and procedures, Organizing, documenting and preparing investigative reports, Written and verbal communications.
* Knowledge of proper methods of interviewing suspects, witnesses and victims, and of the rules regarding the admissibility of statements, admissions and confessions.
* Two or more years of investigative experience preferably in healthcare, government, licensing, Healthcare Insurance, or law enforcement. Certified Fraud Examiner (CFE), or Certified Professional Coder (CPC), AHIMA (CCA), Dental Hygienist (RHD) or Degree in Criminal Justice or other related field or Certification or experience in building code compliance and OSHA policy investigations.
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) 417-4497. 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.
Click the APPLY NOW button to submit your application.
For technical assistance, email HRIShelpdesk@azdoa.gov or call 602-542-4700.