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Pharmacy Fraud Investigator

  • 514995
  • 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.

Pharmacy Fraud Investigator

Office of Inspector General

Job Location:

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

Posting Details:

Open until filled

Salary:  $47,300 - $61,591

Grade: 21

This position may offer the ability to work remotely within Arizona based upon the department's needs and continual meeting of expected performance measures.   

Job Summary:

The Division of Inspector General is looking for a highly motivated individual to join our team as a Pharmacy Fraud Investigator. This position is directly involved in negotiating the final determination of financial over-payments and recommending civil monetary penalties levied against providers regarding prescriptions and pharmaceuticals. This position also investigates AHCCCS members regarding prescription and pharmaceutical fraud, waste, and abuse.

Major duties and responsibilities include but are not limited to:

  • Perform detailed research and data analysis of encounter and claims information gathered from data mining, the AHCCCS mainframe and LexisNexis. Respond to intelligence information requests that include case evaluations, self-audits, ad-hoc reports, data samplings, audits, and interagency requests for information.
  • Perform medical record reviews, CPT coding analysis, and handle provider appeals, and health plan issues related to audit recoveries. 
  • Develop and prepare complex spreadsheets and graphs indicating over payments, misuse of funding and aberrant billings identified through the audit process and data analytic activities. 
  • Identify the civil and/or criminal components of a case, and when appropriate present the criminal evidence to law enforcement for prosecution. 
  • Coordinate with various AHCCCS divisions, AHCCCS providers, health plans, other state agencies, and licensing boards to uphold the integrity of the Medicaid program. 
  • Conduct interviews and obtain written statements from AHCCCS providers to determine if fraudulent activities have occurred. Authority to draft and serve subpoenas and take sworn statements. Prepare written reports for use in administrative or legal proceedings. 
  • Attend meetings, participate in discussion topics, and prepare and present program integrity material for process improvement.
Knowledge, Skills & Abilities (KSAs):

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. 
  • Claims processing, procedures, financing, and operations for Fee For Service and Managed Care Organizations, 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. 

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: 

  • 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. 
  • Function in a virtual office environment.
Qualifications:

Minimum: 

  • Pharmacy Technician License (A.R.S § 32-1923.01) or Pharmacist License (A.R.S §32 -1922) AND Bachelor’s Degree in accounting or closely related field OR years' experience as an Auditor or equivalent. 

Preferred: 

  • Certified Professional Coder (CPC), Certified Fraud Examiner Certification (CFE), and/or eligibility experience. Knowledge of Title 19, ASRS 13 and 36 (is preferred but not required)
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 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 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 (13 and 12 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.