Quality Assurance Investigative Nurse

AHCCCSArizona 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.Quality Assurance Investigative NurseOffice of Inspector General (OIG)Job Location:Address: 150 North 18th Avenue Phoenix, Arizona 85007All AHCCCS Employees must reside within the state of Arizona.Posting Details:Salary: $75,000 - $85,000FLSA Status: ExemptGrade: 22This position will remain open until filled.Job Summary:Under the leadership of the Inspector General and Deputy Assistant Director, this position is responsible for investigation and medical necessity clinical determinations for AHCCCS OIG. These duties include, but are not limited to; investigating, reviewing, evaluating, determining appropriate payment of medical and/or behavioral healthcare services, and medical record reviews with clinical expertise in procedures and processes in the clinical setting. Assurance of compliance with contractual, regulatory, and statutory obligations for AHCCCS members (in both Managed Care Organization (MCO) and Fee for Service (FFS) settings) for physical/acute care services, LTC supports and services, and behavioral health needs and providing subject matter expertise (SME) in a variety of settings. This position is accountable for the prevention and/or resolution of alleged billing concerns, utilization, and determination of any fraudulent activities, waste or abuse of the Medicaid program, identification of criminal activity, and review of system parameters in accordance with AHCCCS rules, regulations and federal guidance. Direct clinical investigative knowledge and expertise is applied by this position in review and timely resolution of the cases assigned, identification of Fraud, Waste and Abuse (FWA) in clinical reviews and collaboration with AHCCCS Divisions, Managed Care Organizations, Law Enforcement Agencies, and other regulatory agencies as identified within the scope of each unique case.Major duties and responsibilities include but are not limited to: • Utilizing clinical knowledge and judgment; conducts complex investigations and performs clinical documentation and evidentiary review of fraud, waste and abuse allegations into medical violations of AHCCCS specific policies and procedures as well as Arizona laws, Statutes, and Federal regulations relating to the AHCCCS programs and care systems. Receive, research, document and resolve cases utilizing standardized processes. To the extent a standardized process does not exist, participate in the creation of a standardized investigation process. Investigations & medical determinations include, but are not limited to: Review CPT coding, level of care, miscoding (including upcoding & unbundling), fraudulent or wasteful billing, incorrect use of services, overutilization, assessment of medical necessity, appropriateness of services, emergency determinations, lengths of stay, services provided within scope of specific clinicians, review of clinically complex members, vulnerable populations, and other items as identified. Reviews medical records and other relevant documentation; conducts investigative interviews and obtains and gathers data to support findings. Collaborates with AHCCCS management at multiple levels and law enforcement regarding findings and recommended actions. • Conduct interviews, participating in surveillance operations, secure evidence, writing complex comprehensive reports, and data analysis. Manage and monitor caseload and timeliness, document actions taken and follow-up actions with case notes. Create and submit high-level reports, extracts, and ad hoc analyses to providers, division management, legal and/or law enforcement staff of the outcome of the investigative and clinical review. Participate in the exchange of information to determine the support of and final outcomes of investigative findings. Supports reviews through the investigative process and hearings if necessary. Ensure these steps occur in compliance of all mandated regulations. • Reviews new/incoming referrals for disposition, referrals to th