Job Description

Provider Compliance Investigator

  • 523578
  • PHOENIX
  • REMOTE OPTIONS
  • AHCCCS
  • Full-time

AHCCCS

Arizona Health Care Cost Containment System
Accountability, Community, Innovation, Leadership, Passion, Quality, Respect, Courage, Teamwork

The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, is driven by its mission to deliver comprehensive, cost-effective health care to Arizonans in need. AHCCCS is a nationally acclaimed model among Medicaid programs and a recipient of multiple awards for excellence in workplace effectiveness and flexibility.

AHCCCS employees are passionate about their work, committed to high performance, and dedicated to serving the citizens of Arizona. Among government agencies, AHCCCS is recognized for high employee engagement and satisfaction, supportive leadership, and flexible work environments, including remote work opportunities. With career paths for seasoned professionals in a variety of fields, entry-level positions, and internship opportunities, AHCCCS offers meaningful career opportunities in a competitive industry.

Come join our dynamic and dedicated team.

Provider Compliance Investigator

Office of Inspector General (OIG)

Job Location:

Address: 801 E. Jefferson Street, Phoenix, AZ 85034

Posting Details:

Salary: $50,000 - $60,000

Grade: 21

Position will remain open until filled

Job Summary:

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 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.
* Develop and prepare complex spreadsheets and flow-charts indicating under payments, misuse of funding and billings obtained through the audit process.
* Develop overpayments: losses to the Medicaid Program through diligent research and review
in order to present the evidence to the legal authorities for prosecution.
* Communicate effectively with the 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 providers and clients to determine if fraudulent activities have occurred.
* Prepare written reports for use in administrative or legal proceedings.

Knowledge, Skills & Abilities (KSAs):

Knowledge of:
* Law Enforcement processes and protocols, Basic investigative techniques
* Interviewing suspects, witnesses and victims, and of the rules regarding the admissibility of statements, admissions and confessions
* 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
* Claims processing, procedures, financing and operations for FFS and MCO
* Preparation of computerized spreadsheets which support audit findings
* Income and resource requirements for eligibility for each of these varied programs, Arizona Revised Statutes, State Personnel Rules

Skilled in:
* Legal decisions as they relate to the admissibility of evidence, confessions, admissions and statements
* 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, conflict resolution

Ability to:
* Interpreting and applying Federal and State Statutes and Agency policies
* Conduct investigations, Manage time effectively, deal with difficult situations in a calm manor
* Effectively handle hostile situations
* Drive a State vehicle
* Function in a virtual office environment

Qualifications:

Arizona Drivers License.

Minimum:
* At least two years' experience as an Auditor OR; Bachelor’s Degree in Accounting, Healthcare, Criminal Justice or a 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 is 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 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 (pilot program).
* 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 program here. For a complete list of benefits provided by The State of Arizona, please visit our benefits page

Retirement:

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.

Contact Us:

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

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.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

Apply Online