Analyst/Auditor – Medicaid Fraud Control Unit (MFCU)

DEFINITION

Under the general direction of the Assistant Attorney General/Director MFCU (Medicaid Fraud Control Unit), this position is responsible for performing highly technical audits of Medicaid
Program providers or comprehensive review of such work as performed by other auditors. Assists in performing various audits and financial investigative procedures on Medicaid providers suspected of having committed fraud or abuse, which includes collecting, evaluating, analyzing data and other evidence, preparing trial exhibits such as graphs, charts, reports. Serves as expert witness during the prosecution of Medicaid fraud cases.

Conducts investigative audits of financial records of health care providers, especially health care facilities, for evidence of fraudulent cost reporting for reimbursement. Collaborates with other investigators, attorneys, and auditors from the Medicaid Fraud Unit. Incumbent supervises the review of financial records, advises, or assists in the investigation of alleged fraud.

Work is reviewed through reports and personal conferences for conformance with professional standards and compliance with established policies and procedures.

This position requires a confidential relationship to a policymaker.

DUTIES (NOT ALL INCLUSIVE)

• Determines scope of audit in coordination with the MFCU Investigators and Attorneys,
  with the objective of producing audit findings that lead to successful prosecution
  or administrative actions based on willful misrepresentation in cost reporting by the provider to the
• Virgin Islands.
• Works with investigative team to plan the financial and audit strategy for criminal and civil fraud investigations.
• Assists other members of assigned audit team, where applicable, in conducting the audit
  and acts as team resources person in accounting and auditing areas.
• Applies generally accepted auditing standards, examines pertinent books and records,
  accountant work papers, and other related financial documents for the purpose of analyzing
  and documenting targeted material deviations from Medicaid policies and procedures.
• Prepares analyses identifying the amounts, types of fraud; prepares reports that summarize the conclusions reached during the investigation.
• Prepares detailed audit work papers cross-referenced to audit program and documents procedures used during the audit with appropriate comments, notations, and exceptions including exhibits where applicable. Specifically, the document will indicate the audit steps performed, disclose findings and conclusions, and will contain comments regarding materiality with response to probable impact on prosecutions and/or administrative actions.
• Prepares and submits preliminary reports to Investigator and/or to the MFCU
  Attorneys, as applicable. Upon completion of investigation and audit, prepares a final
  written report indicating the purpose and scope of all activity regarding the case, including
  a detailed summary of audit findings and interview results, and provides final
  recommendations and priorities with respect to judicial or administrative action.
• Maintains liaison in the conduct of investigations with other areas of the Medicaid Program, e.g., regulatory agencies, law enforcement agencies (federal, state, and local), welfare and public
  health agencies, Medicare carriers, Attorney General and/or Assistant Attorneys General.
• Makes referrals to other agencies, as appropriate.
• Testifies as investigative witness in judicial and/or administrative proceedings resulting
  from an audit and investigation before federal and/or local courts.
• Provides assistance in preparation and enforcement of subpoenas.
• Conducts intensive interviews of criminal suspects, transfers information to investigators, or other law enforcement to provide both preliminary and corroborative evidence obtained.
• Initiates studies and prepares recommendations designed to prevent and/or to deter fraud
  and abuse. Reviews and evaluates existing Program policies and procedures and its
  effectiveness in deterring fraud and abuse.
• Exercises reasonable supervision over the work of auditing the accounting records and
  financial statements of Medicaid Program providers.
• Performs other related duties as required.

FACTOR 1 — KNOWLEDGE REQUIRED BY THE POSITION

• Knowledge of complex and unusual conditions, problems, and issues related to the Virgin Islands Medicaid program.
• Knowledge of generally accepted auditing standards.
• Skill in compiling and analyzing investigative information including financial and/or statistical data.
• Skill in computer operating applications, e.g., Microsoft Office Suite, Word, Excel, Outlook, and PowerPoint.
• Skill in interpersonal communication.
• Skill in handling multiple tasks, prioritizing, and meeting deadlines.
• Ability to work independently and in a team environment.
• Ability to use judgement, tact, and discretion.
• Ability to maintain confidentiality during the performance of work.
• Ability to communicate effectively orally and in writing.
• Ability to serve the public and others in a courteous and professional manner.
• Ability to coordinate and handle multiple tasks with minimal supervision.
• Ability to maintain records, prepare reports, and correspondence related to work.
• Ability to organize work, establish priorities.
• Ability to maintain good working relationships with investigators and support staff, and effective relationships with government officials, DOJ staff, and MFCU partners.
• Ability to receive and respond positively to constructive feedback.
• Ability to maintain case files in compliance with Virgin Islands
• Ability to testify before grand juries, evidentiary hearings, and trials.
• Ability to establish necessary work procedures for analyzing documents and/or records and to prepare complete analysis like summaries, reports, spreadsheets, etc.
• Ability to express oneself in oral and written form clearly and concisely.
• Ability to develop and maintain effective working relationships with members of the Department’s staff and other external entities and bodies.
• Ability to be flexible, proactive, highly motivated, resourceful, organized, professional and efficient.
• Ability to proactively share information and maintain confidentiality when appropriate.

FACTOR 2 — SUPERVISORY CONTROLS

Work is supervised and assigned by the Assistant Attorney General/Director Medicaid Fraud Control Unit (MFCU) or higher-level official. Work is performed independently and collaboratively to maintain good relationships with other agencies to acquire information about new or existing cases. Work is reviewed through reports and consultation with supervisor.

FACTOR 3 — GUIDELINES

Guidelines include departmental rules and regulations, policies, and procedures, MFCU rules and regulations, directives, federal and local laws, the United States Department of Health and Human Services, and Office of the Inspector General rules and regulations, and directives.

FACTOR 4 — COMPLEXITY

The Medicaid Fraud Analyst reviews referrals concerning complex fraudulent schemes that require thorough analysis and understanding of Medicaid polices, billing practices, and medical record documentation.

FACTOR 5 — SCOPE AND EFFECT

The purpose of work is to conduct audits and analysis of related to fraud of the Medicaid Program.

FACTOR 6 — PERSONAL CONTACTS

Contacts are all legal contact needed for prosecution, coworkers, public and associated agencies.

FACTOR 7 — PURPOSE OF CONTACTS

Contacts are made to carry out investigations, obtain background/locating information on Medicaid providers/recipients being investigated, disseminate information, schedule interviews, and verify data.

FACTOR 8 — PHYSICAL DEMANDS

Work is primarily sedentary with occasional walking, standing, bending, and transferring documents.

FACTOR 9 — WORK ENVIRONMENT

Work is performed in an office setting. Some travel may be required.

MINIMUM QUALFICATIONS

Bachelor’s degree in Accounting, Finance, Economics, Criminal Justice, Business Administration or Management, or a related field, which must include at least twelve (12) credit hours of accounting, finance, or management, supplemented by three (3) years of accounting or auditing experience in medical claims and/or claims data.
OR
Associate degree in Accounting, Finance, Economics, Business Administration or Management or a related field from an accredited college or institution, which must include at least twelve (12) credit hours of accounting, finance, or management, supplemented by five (5) years of accounting or auditing in medical claims and/or claims data.