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Member Fraud Investigator

  • 508971
  • PHOENIX
  • REMOTE OPTIONS
  • TUCSON
  • VARIOUS-STATEWIDE
  • 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.

Member Fraud Investigator

Office of Inspector General

Job Location:

Address:  801 E Jefferson St, Phoenix, AZ 85034

Posting Details:

Open until filled: 1st review of resumes on date 6/30/22

Salary: $43,000 - $52,000 

Grade: 21

This position is eligible for part-time/full-time remote work (including virtual office arrangement). Must reside in the State of Arizona. 

Job Summary:

The Office of Inspector General is looking for a highly motivated individual to join our team as a Member Fraud Investigator. This position conducts complex criminal and civil investigations relating to allegations of Medicaid eligibility fraud. Fraud Investigator Major duties and responsibilities of this position include but are not limited to: In depth research investigative report writing, researching Medicaid eligibility rules, policies, statutes. Prepare documentation for Civil and Criminal prosecution. Major duties and responsibilities include but are not limited to:

• Conducts in-depth investigations that include field investigations, surveillance, interviewing and interrogating subjects or witnesses in their home or agency’s office.

• Compiles, analyzes, organizes, Medicaid eligibility records, financial records and other related documents; Composes detailed reports of investigations to submit to prosecuting agencies for criminal prosecution and/or administrative action.

• Conducts investigative internet searches, uses and interprets other investigative sources such as; ACJIS, Experian Credit Reports, CLEAR, Lexis Nexus, Vital Records, AZ Corp. Commission, NWSC, AZ MVD reports, etc.

• Collects, examines, and preserves information, documents, and records for evidence.

• Interprets applicable, federal and state laws, agency rules, regulations and policy regarding Medicaid eligibility and criminal violations

• Serves Subpoena’s to obtain necessary evidence to prove or disprove allegations of Medicaid Fraud

• This position also participates in special projects that may include out of town travel involving residency/eligibility checks of participants as well and on-site audits of certain high risk Medicaid providers. Must be willing to travel overnight if necessary.

Knowledge, Skills & Abilities (KSAs):

Knowledge:
• Criminal, civil and administrative law, Federal Medicaid/Medicare statutes, rules and regulations as they relate to Title 19, 16, & 21 United States Code and additional knowledge of Arizona Revised Statutes, titles 13 and 36, Computerized AHCCCS and the Arizona Department of Economic Security (DES) mainframe systems to effectively extract relevant information, The various types of eligibility programs including but not limited to; Social Security Disability, Long Term Care program, Supplemental Security Income, Temporary Assistance to Needy Families (TANF) program, and the Sixth Omnibus Budget Reconciliation Act (SOBRA).

• Specific knowledge including the income and resource requirements for eligibility for each of these varied programs, 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, The AHCCCS divisions, the services they provide and how they interact with other divisions, Principles of accounting practices and audit techniques.

Skills:
• 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.

Abilities:
• 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.

• Ability to successfully function in a virtual office environment.

Qualifications:

Minimum:
• Any combination of training, experience, and education that meet the KSAs.

Preference:
• CFE Certification, or Medical or Health Care 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.

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 (12 and 13 days per year respectively) - start earning it your 1st day (prorated for part-time employees)
• 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
• Opportunity to work 100% virtually or remotely on an ad-hoc basis (home office)

By providing the option of a full-time or part-time virtual/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.

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. Arizona State Government is an AA/EOE/ADA Reasonable Accommodation Employer.

ARIZONA MANAGEMENT SYSTEM (AMS)

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.

The State of Arizona is an Equal Employment Opportunity Employer.