Fraud Investigator
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.
Fraud Investigator
Office of Inspector General (OIG)
Job Location:Address: 150 North 18th Avenue Phoenix, Arizona 85007
All AHCCCS Employees mustresidewithin the state of Arizona
Posting Details:Salary:$40,000-$49,000
Grade:19
FLSA Status:
Non-Exempt
This position is responsible for conducting investigations to evaluate the accuracy of eligibility determinations for State and Federal programs to prevent ineligible applicants from being approved and discontinuing members who are ineligible to receive benefits. This is a statewide recruitment for a virtual position; however, field investigations and occasional in-office duties in the Phoenix office are required.
Major duties and responsibilities include but are not limited to:- Investigative work to include desk level gathering of evidence and as needed, traveling within the State of Arizona to conduct field and/or desk investigations involving AHCCCS members which includes; interviewing members, observing and documenting pertinent information, gathering data and developing sources of information. Utilizing investigative information to write substantive reports that include evidence review, factual documentation and providing conclusions that support or deny a member's eligibility.
- Review and assess information in the case record; analyze data obtained from all sources, case development, assessing the accuracy of the application, determining expenditures for cost benefit analysis and writing investigative summaries and participating as a witness in the DES grievance process when an investigation was conducted, applicant was ineligible, benefit was denied, and the applicant filed an appeal.
- Planning, scheduling, prioritizing work activity; set up workload controls, determine priorities, monitor activity progress, and set goals.
- Studying statutes, rules, policy manual and clarifications, attending training and conferring with supervisor and others to improve skills and maintain expert level of knowledge.
- Participate in special projects that may include out-of-town travel/overnight travel involving residency/eligibility checks of participants, as well and on-site audits of certain high risk Medicaid providers. Attend in-person trainings and meetings in the Phoenix office.
Knowledge:
- Claims reporting activity
- Microsoft Windows software, Excel spreadsheet software, basic understanding of data base software
- Medicaid Programs and Prepaid Medical Management Information System (PMMIS) and/or DES Eligibility System (AZTECS)
- State statutes, rules and regulations relating to the determination of eligibility for AHCCCS programs, legal and technical terminology for the interpretation of highly diverse forms of verification including, but not limited to, divorce decrees, county property assessment records, medical records, hospital billings, life insurance policies, public assistance benefits and self-employment records
Skills:
- Analyzing case records, evaluation and interpretation of written and verbal information, troubleshooting and problem solving skills
- Research methodologies, independent working skills (requiring a minimum of supervision)
- Interviewing techniques to elicit information
- Verbal and written communication, basic computer skills; this includes the ability to convey, in formal written format, facts and circumstances surrounding an investigation
- Interpersonal relations as applied to contact with benefit recipients, landlords,…
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