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Medicaid Fraud Control Nurse Investigator

Posted
Company
Office of Attorney General
Location
Norristown, Harrisburg, or North Huntingdon
Description

The Medicaid Fraud Control Section (MFCS) is a state law enforcement agency, and its mission is to investigate and prosecute health care providers who have defrauded the Medicaid program.
The section also investigates and prosecutes allegations of abuse and neglect of residents in health care facilities and other settings.
The MFCS utilizes a team-based approach to uncover abuse and neglect of residents and complex financial fraud committed by healthcare providers including hospitals, nursing homes,
pharmacies, physicians, dentists, nurses, and other Medicaid providers. Offenders are held accountable through criminal prosecution.
From inception through disposition, the Nurse Investigator I/II will assist attorneys, agents, auditors, forensic data specialists, and analysts in criminal investigations and prosecutions. The
Nurse Investigator I/II reviews medical records, provides medical guidance and opinions, and assists with investigations in partnership with section staff pertinent to criminal and/or regulatory
investigations alleging Medicaid Fraud, Neglect of a Care-Dependent Person, Abuse of a Care Dependent Person, and other applicable state and federal regulations. This position works
autonomously, with very little day-to-day supervision needed.

Duties Include:

  • Reviews and evaluates allegations of abuse and/or neglect of residents in health care facilities or other settings, and the circumstances surrounding the events, to determine if
    further investigation is warranted.
  • Requests, reviews, and analyzes complex medical documentation and the provision of care delivered by health care providers in all health care settings.
  • Leads or assists MFCS staff in interpreting and analyzing medical records pertaining to an investigation and, if needed, provides written products analyzing or summarizing medical treatment to further investigative needs.
  • Evaluates the implementation of the standards of care.
  • Serves as a resource for the MFCS staff by explaining medical terminology, medical procedures, expected standards of care, and differing responsibilities of health care providers
  • Renders expert opinions regarding the implementation of the provision of care/standards of practice in health care settings.
  • Provides detailed written and oral reports.
  • Assists investigators and prosecutors as a medical resource during interviews.
  • Assists attorneys in case preparation.
  • Testifies at grand jury and trials as needed.
  • Prepares and performs outreach presentations for other state and law enforcement agencies, long-term care staff, and the public regarding the mission of the MFCS to increase awareness and potential referrals of abuse and neglect cases.
  • Works closely with the Pennsylvania Department of Health (DOH) and Department of Human Services (DHS) as well as other state agencies to coordinate investigations,  generate referrals, and to establish relationships to promote the mission of the MFCS.
  • Provides support for the entire MFCS, statewide, which will require travel throughout the state and regions on an as-needed basis
  • Regularly evaluates the section’s procedures and protocols with respect to medical necessity, utilization issues, and patient abuse or neglect, and provides guidance or makes recommendations to the MFCS chief regarding those topics.

In addition to the duties listed above, a Nurse Investigator II will also be responsible for the following additional duties:
• Handles medical reviews of a more advanced complexity, utilizing the higher level of education, training, and experience needed for a Nurse Investigator II
• Trains Nurse Investigator I’s
• Provides guidance and direction to Nurse Investigator I’s, specifically related to medical record reviews, medical guidance and opinions, and investigation assistance conducted by a Nurse Investigator I.

Minimum Experience and Training

  • Graduation from an accredited school of professional nursing and three years of experience as a registered nurse OR Any equivalent combination of education, training, and experience that would enable the individual to perform the duties of the job.
  • Must possess a current Pennsylvania license, issued by the Pennsylvania Board of Nursing, to practice as a registered nurse and must be in good standing.
  • Must possess a valid Pennsylvania driver’s license.
  • Experience in a variety of patient/resident care settings, i.e. long-term care, assisted living, home health, hospice, hospital, and group homes.
  • Knowledge of state and federal rules and regulations related to health care and health care facilities, particularly in the Medicaid program.
  • Preferred Knowledge, Skills, and Abilities
    • Experience in nursing administration, i.e. Director of Nurses, Nursing Administrator, Nurse Supervisor, Charge Nurse, Risk Manager, Quality Assurance Manager
    • Experience as a Centers for Medicare and Medicaid Services (CMS) / DOH certified state surveyor or related experience participating in, or responding to, such certification surveys
    • Experience with drug diversion and abuse/neglect investigations
    • Experience as a legal nurse consultant
    • Certified professional coder
    • Excellent interpersonal, communication, and writing skills

EOE


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