AHCCCS

Salary: $49,500 - $53,840

Grade: 21

This position conducts complex criminal and civil investigations relating to allegations of Medicaid eligibility fraud, including determining the loss to the AHCCCS program. The responsibilities of this position include but are not limited to: In-depth research investigative report writing, researching Medicaid eligibility rules, policies, statutes. Preparing documentation for eligibility determinations, criminal prosecutions and administrative hearings.

Major duties and responsibilities include but are not limited to:
• In-depth investigative work to include desk level gathering of evidence, interviewing members and witnesses, observing and documenting pertinent information, gathering data, developing sources of information, and conducting surveillance. As needed, travel within the State of Arizona to conduct field investigations. Utilizing investigative information to write a substantive reports to substantiate allegations of Medicaid fraud for eligibility determinations, including determining the loss to the AHCCCS program, for criminal prosecution, civil actions, and/or administrative hearings.
• Compile, analyze and organize Medicaid eligibility records, financial records and other related documents, such as marriage records, real estate records, corporate filing records and various database records, to assess the accuracy of eligibility applications. Calculate expenditures associated with fraud, waste and abuse to determine cost-benefit analysis for potential prosecution, civil actions and/or administrative hearings.
• Conduct investigative Internet searches, use and interpret other investigative sources such as; ACJIS, Experian Credit Reports, CLEAR, TLO, Vital Records, Arizona Corporation Commission records and Arizona Motor Vehicle Division reports, etc.
• Interpret and apply federal and state regulations, agency rules, and various agency and state policy manuals to make appropriate eligibility determinations. Participate and testify in the appeals grievance process, coordinate with prosecution agencies, and provide Grand Jury and Court testimony.
• Participate in special projects that may include out-of-town / overnight travel involving residency/eligibility checks of participants, as well as participate in special projects, such as on-site audits of certain high risk Medicaid providers. Attend in-person trainings and meetings in the Phoenix office.
• Prepare and serve subpoenas to obtain evidence necessary to prove or disprove allegations of Medicaid Fraud.

Knowledge:
• 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
• Income and resource requirements for eligibility for each of these varied programs, Arizona Revised Statutes, State Personnel Rules
• Computerized AHCCCS and the Arizona Department of Economic Security (DES) mainframe systems to effectively extract relevant information
• Microsoft Windows, Word and Excel, with the ability to prepare detailed spreadsheets to show how the fraud and accompanying loss of funds to the program was occurred
• AHCCCS divisions, the services they provide and how they interact with other divisions

Skills:
• Legal decisions as they relate to the admissibility of evidence, confessions, admissions and statements
• Research methodologies, independent working skills (requiring minimal supervision)
• 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 surveillance operations 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
• Communicate effectively with stakeholders under adverse arid threatening circumstances.

Abilities:
• Work within a virtual team environment to function effectively in an orderly and purposeful manner in situations of stress or tension
• Interpret and apply Federal and State Statutes and Agency policies
• Ability to understand the investigative process and apply agency standards
• Manage time effectively
• Keep Personal Health Information (PHI), Health Information Portability and Accountability Act (HIPAA), and internal state employee cases confidential
• Work independently in a virtual office environment with little oversight
• The ability to learn and navigate a multitude of agency specific software/programs (PMMIS, HEA, AZTECS, OnBase, etc.)
• Present yourself in a calm and professional manner when dealing with difficult and hostile situations
• Drive a state vehicle
• Ability to travel within the State of Arizona to conduct field investigations, which includes home visits and interviews
• Attend in-person meetings, trainings, and other required functions in the Phoenix office

Arizona Driver's License.

Minimum:
• At least two years of experience as an auditor, investigator or equivalent, or eligibility or case worker experience, which includes Medicaid or other public benefits financial policy background.

Preferred:
• CFE Certification, Bachelor’s Degree in Accounting, Healthcare, Criminal Justice or related field, or 4 years of eligibility or case worker experience, which includes Medicaid or other public benefits financial policy background. 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, ARS 13 and 36.

• 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 maintain 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).

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 program here. 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 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.