Quality Assurance Investigative Nurse

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.