AHCCCS

Address: 150 North 18th Avenue Phoenix, Arizona 85007

All AHCCCS Employees must reside within the state of Arizona.

Salary: $75,000 - $85,000

FLSA Status: Exempt

Grade: 22

This position will remain open until filled.

Under the leadership of the Inspector General and Deputy Assistant Director, this position is responsible for investigation and medical necessity clinical determinations for AHCCCS OIG. These duties include, but are not limited to; investigating, reviewing, evaluating, determining appropriate payment of medical and/or behavioral healthcare services, and medical record reviews with clinical expertise in procedures and processes in the clinical setting. Assurance of compliance with contractual, regulatory, and statutory obligations for AHCCCS members (in both Managed Care Organization (MCO) and Fee for Service (FFS) settings) for physical/acute care services, LTC supports and services, and behavioral health needs and providing subject matter expertise (SME) in a variety of settings. This position is accountable for the prevention and/or resolution of alleged billing concerns, utilization, and determination of any fraudulent activities, waste or abuse of the Medicaid program, identification of criminal activity, and review of system parameters in accordance with AHCCCS rules, regulations and federal guidance. Direct clinical investigative knowledge and expertise is applied by this position in review and timely resolution of the cases assigned, identification of Fraud, Waste and Abuse (FWA) in clinical reviews and collaboration with AHCCCS Divisions, Managed Care Organizations, Law Enforcement Agencies, and other regulatory agencies as identified within the scope of each unique case.

Major duties and responsibilities include but are not limited to:
• Utilizing clinical knowledge and judgment; conducts complex investigations and performs clinical documentation and evidentiary review of fraud, waste and abuse allegations into medical violations of AHCCCS specific policies and procedures as well as Arizona laws, Statutes, and Federal regulations relating to the AHCCCS programs and care systems. Receive, research, document and resolve cases utilizing standardized processes. To the extent a standardized process does not exist, participate in the creation of a standardized investigation process. Investigations & medical determinations include, but are not limited to: Review CPT coding, level of care, miscoding (including upcoding & unbundling), fraudulent or wasteful billing, incorrect use of services, overutilization, assessment of medical necessity, appropriateness of services, emergency determinations, lengths of stay, services provided within scope of specific clinicians, review of clinically complex members, vulnerable populations, and other items as identified. Reviews medical records and other relevant documentation; conducts investigative interviews and obtains and gathers data to support findings. Collaborates with AHCCCS management at multiple levels and law enforcement regarding findings and recommended actions.
• Conduct interviews, participating in surveillance operations, secure evidence, writing complex comprehensive reports, and data analysis. Manage and monitor caseload and timeliness, document actions taken and follow-up actions with case notes. Create and submit high-level reports, extracts, and ad hoc analyses to providers, division management, legal and/or law enforcement staff of the outcome of the investigative and clinical review. Participate in the exchange of information to determine the support of and final outcomes of investigative findings. Supports reviews through the investigative process and hearings if necessary. Ensure these steps occur in compliance of all mandated regulations.
• Reviews new/incoming referrals for disposition, referrals to the appropriate agency for actions, collaborate with internal OIG divisions, and performs case prioritization based on severity and escalation factors.
• Participates in on-going process improvement, work groups, committees, and other special projects to improve efficiency, strengthen program goals, and detect and eliminate identified FWA.

Knowledge:
• State and Federal Policies and Procedures governing Title XIX, Title XXI, NTXIX, Managed Care, FFS, LTC Supports and Services, Behavioral Health and all AHCCCS programs
• Medical/nursing practice, medical case management protocols, utilization review protocols, etc.
• Healthcare delivery system nationally and locally
• Acute nursing processes including assessment, planning, intervention and evaluation
• InterQual or Milliman Criteria, CCI
• Coding: CPT, HCPCS, ICD-10 & Medical Claims Review
• Understanding of health care delivery systems and mechanisms necessary for coordination and delivery of services
• Current standards of medical/behavioral practice and delivery of acute/non-acute medical/behavioral care, Alternative levels of care
• In the area of clinical nursing practices, medical terminology, medical procedures, billing and coding
• Conducting investigative reviews, techniques, and report writing
• AHCCCS policies and procedures, State and Federal statutes, rules and regulations as it applies to the Medicaid program and services covered
• Financial considerations for the state
• Fraud Waste and Abuse

Skills:
• Problem solving identification; evaluation and initiation of appropriate actions; nursing assessment reviews
• Medical case reviews, case investigations or work of considerable difficulty on complex cases requiring a medical and/or clinical knowledge and background.
• Extracting and using information from medical records, documents, and related information to support review and findings
• Interviewing and eliciting information in an investigation; and interpersonal relations, as applied to interaction with providers, members, employers, other state agencies; organization, legal entities, and law enforcement
• Prioritization, and follow through by tracking documents, responses and correspondence related to the outcome of the investigative review
• Written and oral communication to prepare and communicate factual, comprehensive understandable reviews and results
• Public relations skills, interacting with statewide providers of healthcare services, public organizations, and law enforcement agencies
• Strong interpersonal skills in working with people of diverse culture and socioeconomic backgrounds
• Interpretation of rules, laws, and agency policy pertaining to the AHCCCS program

Abilities:
• Assess members from a holistic perspective with an emphasis on recognizing medical, social, environmental and emotional conditions, barriers for meeting medical needs, assess provider duties and obligations towards rendered member treatments
• Read and interpret medical documentation, interpret clinical information and asses implications for treatment
• Prioritize, plan, analyze, coordinate, and manage a heavy caseload; maintain objectivity; produce timely and accurate reports and documentation that support findings; present findings to multiple levels of individuals including management, providers, legal, and law enforcement
• Review, interpret and apply AHCCCS policies, Federal and State statutes and requirements, and knowledge of hierarchy of each pertaining to services
• Effectively work on multiple tasks and varying priorities
• Work in both independent and collaborative settings
• Gather facts, organize, and comprehend complex medical information to make logical interpretations
• Apply clinical knowledge, analytical and problem-solving methods to reviews and determinations of findings
• Exercise good judgment in making strategic decisions in investigative reviews and outcomes.
• Analytical ability to identify and correlate clinical and investigative patterns, initiate investigations, submit findings
• Be productive in a virtual setting

Arizona Driver's License.

Minimum:
• Possession of a license to practice as a registered nurse (RN), Physician’s Assistant (PA) or Nurse Practitioner (NP) in the State of Arizona and three (3) years of relevant experience in healthcare clinical settings.

Preferred:
• Experience in utilization review, investigative experience, knowledge of criminal, civil, and administrative law, and clinical oversight.

• 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. 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.