Fraud Investigator

Arizona State Government; Arizona; Hybrid; USD 40,000 - 49,000; Full time

Benefits offered by this job

10 paid holidays

Paid vacation and sick time

Retirement program

Job summary

AHCCCS (Arizona Health Care Cost Containment System) seeks a Fraud Investigator to conduct investigations of eligibility determinations for State and Federal programs. This statewide recruitment is for a virtual position, with field investigations and occasional in-office duties in the Phoenix office.

The role requires experience in auditing or investigations, a valid Arizona driver’s license, and the ability to travel within the state for field work.

Qualifications

• Experience in auditing work, investigations or public benefits eligibility.
• Bilingual (Spanish) is a plus.
• Investigative experience in fraud, healthcare or other related fields; experience in public benefits eligibility; law enforcement experience or audit experience.

Responsibilities

• Investigative work to gather evidence, interview members, and write reports to support or deny eligibility.
• Review information in case records, analyze data, and participate as a witness in the DES grievance process when needed.
• Plan, schedule, prioritize work, and monitor progress.
• Study statutes and policy manuals to maintain knowledge and ensure proper eligibility determinations.
• Participate in special projects including travel for residency/eligibility checks and on-site audits.

Skills

Claims reporting activity

Microsoft Windows software

Medicaid Programs

State statutes

Analyzing case records

Research methodologies

Interviewing techniques

Verbal and written communication

Interpersonal relations

Tactful diplomacy

Teamwork

Public interactions

Calm under pressure

Hostile situations

Travel (state)

Virtual work proficiency

Independent work

Field investigations

Education

Bachelor’s degree in accounting, Healthcare, Criminal Justice or closely related field

Tools

AZTECS PMMIS

Job description

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.

FraudInvestigator

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

Job Summary:

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, Skills & Abilities (KSAs):

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, employers, public and private organization representatives
• Use of tactful diplomacy due to the nature of the job

Abilities:

• Work within a team environment, function effectively in an orderly and purposeful manner in situations of stress or tension
• Work with the public in less than ideal conditions
• Deal with difficult situations in a calm manor
• Effectively handle hostile situations
• Drive a State vehicle
• Deal with multiple tasks at one time
• Successfully work and be productive in a virtual environment
• Work independently with little oversight
• Travel within the State of Arizona to conduct field investigations, which includes home visits and interviews
• Attend in person trainings and meetings in the Phoenix office

Qualifications:

Arizona Driver's License.

Minimum:

• Experience in auditing work, investigations or public benefits eligibility.

Preferred:

• Bachelor’s degree in accounting, Healthcare, Criminal Justice or closely related field. Experience of the rules regarding the admissibility of statements, and confessions; Title 19 and ASRS title 13 & 36. Bilingual (Spanish) is a plus. Investigative experience in fraud, healthcare or other related fields; experience in public benefits eligibility; law enforcement experience or audit experience.

Pre-Employment Requirements:

• 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.)

Driver’s License Requirements.

All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).

Benefits:

• 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.

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 [e-mail].

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.