Position Summary:
The Oklahoma Medicaid Fraud Control Unit (MFCU) is a state law enforcement agency, and its mission is to investigate, prosecute, and conduct civil enforcement actions against, health care providers who have defrauded the Medicaid program. The MFCU also investigates, prosecutes and pursues civil enforcement actions regarding allegations of abuse, neglect, and exploitation of residents in health care facilities. This position will be located in downtown Oklahoma City, in a high-rise office building located near Kerr Park.
The MFCU utilizes a team-based approach to uncover abuse, neglect and exploitation of residents, and investigate complex financial fraud committed by healthcare providers, (including hospitals, nursing homes, pharmacies, physicians, dentists, nurses, and other Medicaid providers). The MFCU holds offenders accountable through criminal prosecution and civil enforcement actions. From inception through disposition of a case, the nurse will assist attorneys, investigators, and forensic auditors in criminal and civil investigations and enforcement actions.
Responsibilities
Duties & Responsibilities:
- Review and evaluate allegations of abuse and/or neglect or exploitation of residents in health care facilities, and the circumstances surrounding the events, in collaboration with other MFCU professionals to determine if further investigation is warranted.
- Request, review, and analyze complex medical documentation and the provision of care delivered by health care providers in all health care settings. Evaluate the implementation of the standards of care.
- Communicate effectively and professionally with persons within and outside the organization.
- Procure (by legal and appropriate means), analyze, and interpret computerized data, financial records, billing records, medical records, legal documents, and other material in the pursuit of evidence of fraud and abuse, neglect, and exploitation of Medicaid recipients or otherwise in the residential care settings.
- Analyze, process, and compile findings and information from healthcare coding, billing, and claims data. Apply appropriate regulations, policies, and procedures to determine accurate reimbursable services and eligibility of providers as requested.
- Locate, interview, and write reports on information gathered from medical records, potential witnesses and suspects, including Medicaid providers, their employees, recipients, and others who may have knowledge pertinent to evaluating whether Medicaid providers have violated state and/or federal laws.
- Work with the investigative team to team to develop investigative plan. Collaborate with attorneys to prepare accurate subpoenas in order to obtain materials and documentation relevant to the investigation. Locate, collect, and preserve evidence of criminal or civil fraud, or abuse and/or neglect.
- Work with the investigative team to develop accurate and detailed reports of investigative findings with recommendations, with appropriate justification for civil, criminal, or administrative action. Summarize investigative activities including statements, investigative reports, witness lists, chain(s) of evidence/custody, subpoena(s), affidavits, and any other case-related materials or pertinent information deemed necessary for a successful criminal prosecution or civil lawsuit.
- Testify in court proceedings as needed.
- Serve as a resource for the MFCU staff by explaining medical terminology, medical procedures, the correct billing of services provided, expected standards of care, and differing responsibilities of health care providers. Render expert opinions regarding the implementation of the provisions of care/standards of practice in health care settings. Provide detailed written and oral reports. Assist investigators and prosecutors as a medical resource during interviews.
- Prepare and participate in outreach presentations for other state and law enforcement agencies, long-term care staff, private enterprises, and the public, regarding the mission of the MFCU, in order to increase awareness and potential referrals of abuse, neglect, and exploitation cases.
- Works closely with outside law enforcement entities, and other state agencies, to coordinate investigations, generate referrals, and to establish relationships to promote the mission of the MFCU.
- Attend trainings in order to stay current with trends and information regarding nursing and medical care.
Additional duties and responsibilities may be added at the discretion of the supervisors and/or Director.
Qualifications
Qualifications:
Qualified candidates must have:
- Graduation from an accredited school of professional nursing
- Active Oklahoma state licensure in good standing
- At least five (5) years of experience as a registered nurse
- Valid Oklahoma driver’s license
- Excellent interpersonal, communication, and writing skills
- Strong organizational skills
Preference will be given to candidates with:
- Experience in a variety of patient/resident care settings (long term care, assisted living, home health, hospice, hospital, group homes)
- Knowledge of state and federal rules and regulations related to health care and health care facilities, particularly in the Medicaid program
- Experience in nursing administration: Director of Nurses, Nursing Administrator, Nurse Supervisor, Charge nurse, Risk Manager, Quality Assurance Manager
- Experience with drug diversion and abuse/neglect investigations
- Experience as a legal nurse consultant
- Certified professional coder
All applicants must agree in writing to complete, and satisfactorily pass, a background investigation.
Application Process
How to Apply:
Send a cover letter and resume to resumes@oag.ok.gov with “Nurse Analyst” in the subject line of the email.
Stevens Amendment statement: The Oklahoma Attorney General’s Office Medicaid Fraud Control Unit receives 75% percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $3,891,683.17 for Federal fiscal year (FY) 2024. The remaining 25% percent, totaling $1,177,536.00 for FY 2024, is funded by the State of Oklahoma. The federal fiscal year 2023 is defined as October 1, 2023, through September 30, 2024.
The Oklahoma Office of the Attorney General is an equal employment employer and does not make hiring decisions on the basis of race, sex, sexual orientation, gender identity, color, age, national origin, genetic information, religion, or disability, so long as the disability does not render the person unable to perform the essential functions of the position for which employed with a reasonable accommodation. All employees of the Oklahoma Office of the Attorney General are “at will” employees.
