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MEDICAID FRAUD INVESTIGATOR
The Medicaid Fraud Investigator is responsible for investigating allegations, complaints, and/or incidents, collecting evidence and statements, compiling information and evidence, and preparing the investigative report and case file pertaining to provider fraud and abuse. This position is governed by state and federal laws, and agency/institution policy.
Class Code:
Job Grade:
Special Job Requirements:
None
Typical Functions:
Assists in planning and conducting complex Medicaid provider investigations of allegations, complaints, and/or incidents by gathering evidence and documentation, identifying and interviewing employees, complainants, witnesses, clients, vendors, contractors, etc., and evaluating findings, and visiting locations to monitor programs, services, and/or policies, procedures, and practices.
Compiles and analyzes information and evidence collected, reviews current or previous legal actions or similar allegations and complaints and determines if additional investigative techniques are needed, implements additional techniques, and coordinates the investigative process internally and externally.
Prepares a comprehensive investigative report including the investigative process, summary and findings, and the case file with evidence, interviews, documentation, etc.
Evaluates actions of participants and may conduct computerized voice stress analysis tests or criminal background checks via the Arkansas Crime Information Center (ACIC) or National Crime Information Center (NCIC) to determine criminal history of current or prospective participants.
Maintains logs and records of allegations, complaints, and/or incidents and investigative findings for retrieval purposes.
Provides testimony at legal proceedings or administrative hearings regarding the investigation and its outcome.
Reviews policy and procedure and recommends appropriate actions for compliance purposes, assists with preparation of policy and procedure and correspondence, training and workshops, and makes presentations to groups, committees, or meetings.
Performs other duties as assigned.
Knowledge, Abilities, and Skills:
Knowledge of state and federal laws and regulations governing Medicaid programs.
Knowledge of investigative methods and legal research methods and procedures.
Knowledge of healthcare system and services.
Ability to research, develop, implement, interpret, and apply state and federal laws and operational policies related to service area.
Ability to collect data and conduct investigations internally and externally.
Ability to prepare and present oral and written information and investigative reports.
Ability to coordinate services with other state and federal investigative units, local, state and federal agencies, and attorneys.
Ability to utilize Microsoft software.
Minimum Qualifications:
The formal education equivalent of a bachelors degree in criminal justice, accounting, auditing, business administration, public administration, or a related field; plus five years of progressively more responsible experience in conducting investigations, compliance auditing, or financial reviews within a healthcare, financial, or related program.
Additional requirements determined by the agency for recruiting purposes require review and approval by the Office of Personnel Management.
OTHER JOB RELATED EDUCATION AND/OR EXPERIENCE MAY BE SUBSTITUTED FOR ALL OR PART OF THESE BASIC REQUIREMENTS, EXCEPT FOR CERTIFICATION OR LICENSURE REQUIREMENTS, UPON APPROVAL OF THE QUALIFICATIONS REVIEW COMMITTEE.
Required Certificates:
None
Exempt:
