Fraud Investigator

FLSA Status: Non-Exempt

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