AHCCCS

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

Salary: $50,000 - $60,000

Grade: 21

Open Until Filled

The purpose of this position is to uphold the integrity of the Medicaid program through data analysis, ad hoc claim/encounter reports, case evaluations, audits, investigations, and an assortment of program integrity projects. The reports and evaluations are used for a variety of purposes including: decisions regarding the opening and closing of criminal and civil investigations, and determination of fines, restitution and cost avoidance. The employee is also responsible for recommending and interpreting Medicaid policies, CPT coding, MCO and provider contract language, and Arizona State Statutes and Administrative Codes that pertain to Medicaid 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 OIG analytical systems. Maintain thorough and detailed case notes for each investigation. Respond to intelligence information requests that include case evaluations, self-audits, ad-hoc reports, random sample requests, global data requests, pharmacy reports, data samplings, audits and inter-agency requests for information.
• Perform medical record reviews, CPT coding analysis, and handle provider appeals and health plan issues related to audit recoveries; Identify AHCCCS policies, state and federal regulations pertinent to audits and investigations performed by PIT, and conduct ancillary investigations as well as investigations as required based on the needs of the Program Integrity Team.
• 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. Maintain and update shared team spreadsheets accurately.
• Identify the civil and/or criminal components of a case, and when appropriate present the criminal evidence to law enforcement for prosecution. Follow rules of evidence in maintaining documents, retention and disposition.
• 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:
• Claims and encounter processing
• HIPAA
• CPT coding
• Medical records
• Microsoft Office (especially Excel)
• Arizona revised statutes
• Medicaid and Medicare fraud, waste and abuse statutes
• Investigative techniques

Skills:
• Data analytics
• Investigative methods
• Program compliance auditing
• Preparation of detailed spreadsheets
• Medical record analysis
• Problem solving
• Application of appropriate laws, regulations and policies
• Written and verbal communication
• Research analysis
• Team oriented

Abilities:
• Analyze healthcare data for fraud, waste and abuse
• Prepare reports in a clear and concise manner
• Drive a state vehicle
• Conduct a logical investigation as necessary

Minimum:
• At least two years' experience as an Auditor or equivalent or Bachelor’s Degree in Accounting, Healthcare, Criminal Justice or 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.

• 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.

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 (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

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.