Clinical Health Care Investigator, Medicaid Fraud & Abuse Division, Spokane

Full Job Description

Persons requiring reasonable accommodation in the application process or requiring information in an alternative format may contact the recruitment team at HREmployment@atg.wa.gov.

Those with a hearing impairment in need of accommodation are encouraged to contact the Washington Relay Service at 1-800-676-3777 or www.washingtonrelay.com.

The Attorney General’s Office is recruiting for a permanent full time Clinical Health Care Investigatorin the Medicaid Fraud & Abuse Division. This position is located in Spokane, Washington, and is represented by the Washington Federation of State Employees (WFSE).

Clinical Health Care Investigator Salary Range 70N: $89,904 - $147,312
The base pay offered will take into account internal equity and may vary depending on the preferred candidate’s job-related knowledge, skills, and experience.

The following stipends may apply based on position requirements:

• Incumbents assigned to a position designated as requiring dual language skills will receive a 5% Dual Language Requirement Pay stipend.

The AGO provides a workplace that is understanding of work-life balance and promotes advancement by offering a wide variety of professional development and growth opportunities.

Excellent benefitsWashington State offers one of the most competitive benefits packages in the nation, including Medical/Dental/Vision for employees & dependent(s); Vacation, Sick, and Other Leave; 11 Paid Holidays per year; Public Employees Retirement System (PERS) plans; and Life Insurance.

Beyond these traditional benefits, we offer Dependent Care Assistance, Flexible Spending Accounts, Public Service Loan Forgiveness, Tuition Waiver, Deferred Compensation, Employee Recognition Leave, and more.

With the goal of employee health and wellness, we also offer:

• Flexible schedules and part-time/hybrid telework options;
• A Wellness Program, an Infants in the Workplace Program, and the Employee Assistance Program, which provides counseling, webinar, and other cost-free support resources;
• Numerous employee-driven affinity groups to foster community and connection, including Bereavement, Elder Care, Parenting, POC, LGBTQ+, Veterans and more. The AGO is a place to belong and make a difference!

About the Medicaid Fraud & Abuse Division

Established in 1978, the Washington State Medicaid Fraud & Abuse Division (MFAD) is a Law Enforcement Agency responsible for both criminal and civil investigation and prosecution of healthcare provider fraud committed against the State’s Medicaid program.

The division also investigates and prosecutes complaints of resident abuse or neglect in nursing homes, adult family homes and assisted living. RCW 74.66 and 74.67.

The work of the Office’s Medicaid Fraud & Abuse Division focuses on both criminal and civil law enforcement and is 75% federally funded. MFAD‘s mission is combating provider fraud, abuse and neglect in residential facilities and involving Medicaid recipients in non-institutional settings.

MFAD’s Headquarters is located in Olympia, Washington with some team members also located at the AGO's Spokane Office and Seattle Office.

The Division currently has a staff of 83 FTEs, including attorneys, special agents, digital forensics investigators, data analysts, clinical health investigators and professional support staff.

MFAD involves protecting not only the Medicaid program of roughly 22.9 billion dollars per annum, but also its most vulnerable persons, typically elderly persons in residential facilities or persons abused or neglected by a Medicaid Provider.

In many of our cases, there is no precedent, so MFAD is consistently on the cutting edge of legal theories and issues.

The cases range from abuse and neglect of persons in nursing homes, large scale organized individual and corporate civil and criminal fraudulent activity to national whistleblower actions.

Our staff is a highly professional, fun and seasoned analytical investigative team.

MFAD is unique in that all cases have an attorney, special agent, data scientist and medical specialist assigned with legal support.

This, and the great people who make up the division, gives MFAD a particularly terrific team atmosphere.

Duties and Essential Functions of a Clinical Health Care Investigator

Provides essential medical clinical advice as well as complex analysis of medical charts, data, areas of inquiry, medical issues, facility operations and clinical practice of Medicaid provider fraud and patient abuse & neglect as set forth in 42 USC 1396b(q)(4) throughout all phases of a matter.

Creates and executes investigative plan for medical portions of the investigations.

Perform complex clinical analysis, investigation and assessment of: Medicaid claims, billing data, and medical records from a variety of provider types, regarding the following, to include but not limited to: (1) provision of medical services; (2) standard of care followed; (3) care plan adherence; (4) medical coding and billing; (5) any aberrant billing patterns; (6) medically necessary services; (7) providers complied with Medicaid policy, regulations as well as the profession’s licensing & other professional requirements; (8) diagnoses were consistent with the treatment billed; (9) contraindicated treatments / medications; and (10) gaps in the provider's medical documentation exist.

Provides essential medical expertise, investigative techniques and advice to MFAD prosecutors, data analysts, financial examiners and field investigators and creates/ renders complex medical clinician analysis and investigation into the (1) medical aspects of investigative plans; (2) medical terminology; (3) medical services; (4) Medicaid Program rules, regulations, and policies; and (5) medical coding.

Perform complex analysis of medical records, charts, medication administration records, Minimum Data Set resident assessment instruments, ICD-9 & 10/CPT, HCPC coding and other coding instruments; Medicaid claims/utilization data (e.g.

reviews CPT codes to ensure consistency with notes and information provided by medical personnel in charts).

Provides essential clinically complex analysis and judgment in synthesized detailed reports (interview, assessment or analysis), verbal and in writing as requested, stating clinical conclusions when requested.

Provides essential medical and clinical advice to investigators and prosecutor as they prepare search warrants, special inquiry judge’s subpoenas, vendor requests or demand letters.

Provides essential technical medical assistance during search warrant execution to assist field investigators in identifying items for seizure. Conducts interviews regarding medical issues as well.

Provides essential clinician viewpoint advice and facilitates the identification, recruiting, and preparation of medical/healthcare expert witnesses.

Testifies in legal proceedings and provides critical medical concept explanations in terms that a layperson easily understands.

This recruitment announcement may be used to fill multiple positions for the same classification, in addition to the position(s) listed in this announcement.

Required Qualifications

A valid Washington State license to practice in one of the following professions: allopathic or osteopathic physician, physician assistant, registered nurse (RN), or advanced registered nurse practitioner (ARNP).

PLUS

Five (5) years of professional health care experience in a clinical setting as an allopathic or osteopathic physician, physician assistant, RN and/or ARNP.

Skills & Abilities

The most competitive candidates will possess the following preferred qualifications:

• Possess a high degree of knowledge regarding medical coding and billing procedures, particularly in long-term residential care.

• Experience in long-term residential care, clinical and administrative.

• Experience in medically related investigative techniques.

• Experience conducting complex clinical analysis and report writing.

• Experience in medical legal consulting

Conditions of Employment

A background check consisting of employment history, professional references and educational verification (e.g., degree, license, or official transcript) may be conducted.

Prior to any offer, the applicant selected will be required to submit to and pass a fingerprint-based criminal background check conducted by the Washington State Patrol, Criminal Records Division.

The incumbent will submit to additional background checks as a condition of employment every five (5) years thereafter.

About the Washington State Office of the Attorney General The Attorney General’s Office (AGO) touches the lives of every resident in this state.

We serve more than 230 state agencies, boards, commissions, colleges and universities, as well as the Legislature and the Governor.

The Office is comprised of nearly 700 attorneys and 800 professional staff, all working together to deliver the highest quality professional legal services to Washington state officials, agencies, and entities.

This includes:

• Economic justice and consumer protections (safeguarding consumers, protecting youth, seniors, and other vulnerable populations)
• Social justice and civil rights (addressing discrimination, environmental protection, and veteran and military resources)
• Criminal justice and public safety (investigative and prosecutorial support, financial crimes)
• And much more!

Our agency also has national reach, representing the State of Washington before the Supreme Court, the Court of Appeals and trial courts in all cases that involve the state’s interest. If you want to make a difference, we may be the perfect fit for you! Learn more about the AGO here.

Commitment to DiversityDiversity is critical to the success of the mission of the AGO.

This means recognizing, respecting, and appreciating all cultures and backgrounds-- and fostering the inclusion of differences between people.

Appreciating, valuing and implementing principles of diversity permits AGO employees to achieve their fullest potential in an inclusive, respectful environment.

One recent measure of the AGO's commitment to diversity can be found in its nomination for Rainbow Alliance and Inclusion Network's "Outstanding Agency Award" in 2019.

Our commitment to employee wellness is reflected in earning the 2024 Zo8 Washington Wellness Award.

Application Instructions

In addition to completing the online application, applicants must attach the following documents to their profile in order to be considered for this position:

• A letter of interest, describing your specific qualifications for the position;
• A current resume detailing experience and education.

Read the Following Information Completely:

• Carefully review your application for accuracy, spelling and grammar before submitting.
• You may not reapply to this posting for 30 days.
• The initial screening of applications will be solely based on the contents and completeness of the “work experience” and “education” sections of your application in www.careers.wa.gov, completeness of the application material submitted, and responses to the supplemental questionnaire.
• A resume will not substitute for completing the “work experience” section of the application.

• All information may be verified and documentation may be required.
• The Washington State Office of the Attorney General does not use the E-Verify system; therefore, we are not eligible to extend STEM Optional Practical Training (OPT). For more information, please visit www.uscis.gov.

Equal Employment Opportunity and Accommodations Requests

Honoring diversity, equity and inclusion means that as an agency, and as individuals, we are committed to ensuring that all employees and volunteers enjoy a respectful, safe and supportive working environment.

Only by fostering the inclusion of people from all backgrounds, cultures and attributes, can AGO employees and volunteers achieve their fullest potential and best advance the goals and mission of the AGO.

The AGO is an equal opportunity employer and does not discriminate on the basis of race, creed, color, national origin, sex, marital status, sexual orientation/gender identity, age, disability, honorably discharged veteran or military status, retaliation or the use of a trained dog guide or service animal by a person with a disability.

Persons requiring reasonable accommodation in the application process or requiring information in an alternative format may contact the recruitment team at HREmployment@atg.wa.gov.

Those with a hearing impairment in need of accommodation are encouraged to contact the Washington Relay Service at 1-800-676-3777 or www.washingtonrelay.com.

For questions regarding this recruitment or assistance with the application process, please contact the recruitment team at HREmployment@atg.wa.gov.

If you are having technical difficulties creating, accessing or completing your application, please call NEOGOV toll-free at (855) 524-5627 or support@neogov.com.