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Title : Auditor 3

Title : Auditor 3

Arizona Health Care Cost Containment SystemPhoenix, AZ
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Job Summary :

This position is directly involved in negotiating the final determination of financial over-payments and recommending civil monetary penalties levied against providers participating in fraudulent billing practices. The information obtained by this position is used for a variety of activities such as : determination of fines, restitution and cost avoidance; internal deliberation's regarding settlement amounts for fines and restitution, participate in the decisions regarding opening and closing of criminal and civil investigations.

Major duties and responsibilities include but are not limited to :

  • Complete required health care fraud audits to establish if program violations have occurred through billing, health care records, financial documentation, access to mainframe computer systems at AHCCCS, DES, MVD and DPS.
  • Develop and prepare complex spreadsheets and flow-charts indicating under payments, misuse of funding and billings obtained through the audit process.
  • Develop overpayments : losses to the Medicaid Program through diligent research and review in order to present the evidence to the legal authorities for prosecution
  • Communicate effectively with the providers and contractors occasionally under adverse arid threatening circumstances. Authority to draft and serve subpoenas and take sworn statements
  • Conduct interviews and obtain written statements from providers and clients to determine if fraudulent activities have occurred.
  • Prepare written reports for use in administrative or legal proceedings
  • Other duties as assigned as related to the position (typically 5% - 10%)

Knowledge, Skills & Abilities (KSAs) :

Knowledge :

  • Law Enforcement processes and protocols, Basic investigative techniques
  • Proper methods of interviewing suspects, witnesses and victims
  • 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 FFS and MCO
  • 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
  • Medical coding and billing practices

    • Skills :

  • Computing, summarizing, and aggregating qualitative and quantitative data in an accurate and timely manner
  • Investigative methods, techniques and approaches necessary to plan and conduct program compliance audits
  • Interpreting and applying federal and state laws, rules, regulations, and procedures
  • Organizing, documenting and preparing investigative reports
  • Effective verbal communication

    • Abilities :

  • Prepare written documentation in a clear and concise manner
  • Learn compliance as it relates to Healthcare, AHCCCS Providers, and AHCCCS member safety

    • Qualifications :

    Arizona Driver's License.

    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.

    • 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.)

    • 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).

    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)
  • 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 pilot program here.

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