Job Code Pay Scale Group Pay Scale Type Bargaining Unit Civil Service or Non-Civil Service Last Executive Board Change Executive Board Change History
43350 11 ST F3 N 999-99 09/13/2018
Click on “Job Code” for current expanded job information.

12/08/2009 43350


DEFINITION: This is highly responsible administrative work directing programs to determine possible misuse, abuse or fraud in the Medical Assistance (MA) Program and to identify the use of and recovery from third-party benefits available to MA recipients.

The employee in this job directs the formulation and implementation of policies, plans and strategies for detecting and correcting MA abuse or fraud. Work involves planning, organizing, and directing the review processes of claims invoices and encounter data submitted by MA service providers and managed care organizations (MCOs) for services delivered to recipients to determine or detect possible abuse or fraud. Work also involves directing the Estate Recovery and the Health Insurance Premium Payment (HIPP) Programs and the federally mandated cost containment program involving the investigation and recovery of monies owed to the department from third-party entities for benefits received by MA recipients but erroneously paid by the MA program. Work involves analyzing and evaluating MA program goals and objectives and reviewing MA providers to ensure that all services have been provided in accordance with applicable MA regulations and policies. Work also involves ensuring that all third-party benefits available to MA recipients are utilized and exhausted before payment by the MA program and that monies from third parties are recovered whenever possible. Work includes directing the investigation of providers and recipients and initiating corrective or legal action and follow-up through appropriate departments and law enforcement agencies. Supervision is exercised over a professional, technical and clerical staff. The employee is required to exercise initiative and independent judgment in reviewing and enforcing department program regulations and policies. Work is performed under the general administrative direction of the Deputy Secretary for Administration, DHS and is reviewed through conferences, reports and evaluation of the results achieved.

EXAMPLES OF WORK: Directs the formulation and implementation of policies for detecting and correcting MA abuse or fraud and the investigation and recovery of third-party liability for MA claims, and advises the deputy secretary and program administrators on interpretation and implementation.

Manages the federally mandated cost containment program involving the investigation, determination and recovery of third-party liability of previously paid MA claims.

Plans, organizes and directs the development and implementation of a comprehensive review program to detect fraud and abuse in the fee-for-service and MCO delivery systems.

Reviews, analyzes, evaluates and revises the review procedures to effectively meet program requirements.

Provides direction and technical assistance in reviewing reports regarding service delivery, claims invoices, and encounter data to detect potential abuse or fraud and to determine third-party liability.

Educates providers and encourages program compliance through speaking engagements, the issuance of MA Bulletins and other means.

Directs the investigation and gathering of supportive documentation for preparation of abuse or fraud cases for administrative or legal corrective action.

Coordinates activities to initiate corrective or legal action and follow up through law enforcement agencies in cases of MA abuse or fraud.

Prepares written reports and recommendations for program improvement.

Provides technical assistance, education and support to MCO special investigation units to ensure compliance with relevant contractual requirements.

Directs and manages the use of technology to review paid claims and encounter data and identify cases of potential fraud and abuse.

Performs the full range of supervisory duties.

May participate in the performance of subordinate's work consistent with operational or organizational requirements.

Performs related work as required.

REQUIRED KNOWLEDGES, SKILLS, AND ABILITIES: Knowledge of the principles and practices of program planning.

Knowledge of the principles and practices of public administration.

Knowledge of the principles of employee supervision.

Knowledge of social, economic and health problems and the available resources to resolve these problems.

Ability to read, analyze and interpret policies, procedures and regulations.

Ability to analyze and interpret written and numerical information.

Ability to maintain effective working relationships.

Ability to communicate effectively orally.

Ability to communicate effectively in writing.

MINIMUM EXPERIENCE AND TRAINING: Six years of experience in human services provision, including two years in a supervisory capacity and a bachelor's degree;


An equivalent combination of experience and training which includes two years of experience in human services provision in a supervisory capacity.