This is field investigatory work with responsibility for determination of compliance with State and Federal laws, rules, and regulations. Work involves performing desk and field investigations, ascertaining facts and obtaining evidence involving claims submitted by providers of service, and receipt of benefits by recipients. Incumbents prepare reports of activities, maintain accurate records of findings, and testify in court or administrative hearings as necessary. Work is performed under the general direction of the Branch Director or immediate supervisor and is reviewed through periodic reports and conferences.
Examples of Work:
Examples of work performed in this classification include, but are not limited to, the following:
Travels frequently for the investigation of Medicaid providers/recipients.
Investigates providers/recipients of service under the Medicaid Program to determine compliance with State and Federal laws, rules and regulations.
Makes a thorough examination of records to determine that services for which Medicaid has been billed and has paid have been provided to the recipients; contacts recipients in home settings for verification of billed services and to obtain necessary facts and statements relating to recipient card abuse cases.
Conducts in-depth investigations of all provider cases involving suspected fraud and/or abuse preliminary to an administrative hearing or the initiation of a civil or criminal action.
Appears as an expert witness by testifying at Board disciplinary hearings and in Federal and State Court.
Compiles and completes investigative reports for agency accountability and administration.
Maintains liaison with other regulatory and enforcement personnel of federal, state, and local government.
Confers with medical consultants, representatives of professional organizations, and others to provide instruction, obtain advice, coordinate policies and procedures, and resolve common problems related to the Medicaid program.
Researches, collects, and analyzes Medicaid data from data sources including recipients, providers, manuals, reporting systems, professional references, fee schedules, and other sources to answer questions and resolve problems.
Performs desk and field investigations of providers/recipients under the Medicaid program.
May handle intensive field examination of employer, bank, courthouse, and collateral contract records to determine that services for which Medicaid has paid were eligible to be received by the recipients; contacts recipients in home settings for verification of report eligibility factors.
Performs related or similar duties as required or assigned.
These minimum qualifications have been agreed upon by Subject Matter Experts (SMEs) in this job class and are based upon a job analysis and the essential functions. However, if a candidate believes he/she is qualified for the job although he/she does not have the minimum qualifications set forth below, he/she may request special consideration through substitution of related education and experience, demonstrating the ability to perform the essential functions of the position. Any request to substitute related education or experience for minimum qualifications must be addressed to the State Personnel Board in writing, identifying the related education and experience which demonstrates the candidate's ability to perform all essential functions of the position.
A Bachelor's Degree from an accredited four-year college or university.
Graduation from a standard high school or equivalent (GED);
Four (4) years of experience related to the described duties.
Related education and related experience may be substituted on an equal basis.
Must possess a valid driver's license, as verified by the hiring agency.
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