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Member Fraud Investigator

  • 503153
  • Full-time
  • Closing at: Nov 28 2021 at 23:55 MST


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. 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. AHCCCS employees are passionate about their work, committed to high performance, and dedicated to serving the citizens of Arizona.

Member Fraud Investigator

Posting Details:

Salary: $43,000 - $52,000 

Grade: 21

Closing Date: 11/28/2021

Job Summary:

This position is open only to current State of Arizona employees.

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:

Job Duties:

• 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 of: 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.

• 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.

• Ability to successfully function in a virtual office environment.

Selective Preference(s):

• 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:

• Arizona drivers license.


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.

For a complete list of benefits provided by The State of Arizona, please visit our benefits page

Contact Us:

Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by contacting 602-417-4497.
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.


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.