The Attorney General has broad oversight of the state’s legal and law enforcement matters. As the head of the Department of Law and Public Safety, the Attorney General supervises a wide range of Divisions, Offices, and Commissions, consisting of over 2,800 sworn law enforcement officers, 600 attorneys, and thousands of other public servants.

ABOUT THE DIVISION:

The Office of the Insurance Fraud Prosecutor (OIFP) is responsible for investigating, prosecuting, and deterring insurance fraud and serves as the statewide coordinator for all anti-insurance fraud efforts in New Jersey with more than 50 detectives and 20 prosecutors, OIFP investigates a range of complex fraud schemes.

ABOUT THE SECTION:

The New Jersey Medicaid Fraud Control Unit (MFCU) is to protect Medicaid beneficiaries and the Medicaid Program from fraud, waste and abuse. The Medicaid Fraud Control Unit is within the New Jersey Office of the Insurance Fraud Prosecutor. The MFCU investigates and prosecutes healthcare Providers who are suspected of defrauding the Medicaid Program, fraudulent activities by providers against the Medicaid program, fraud in the administration of the program, fraud against other federally funded health care programs where there is a Medicaid nexus, complaints of patient or resident abuse or neglect in health care facilities receiving Medicaid funding such as nursing homes. Also those Medicaid beneficiaries who reside in any other setting outside their home where care is provided to them. Abuse and/or neglect means both physical abuse or neglect and fiscal pertaining to money or property abuse or neglect and Violations of the Civil False Claims Act, where the alleged fraud impacts Medicaid.

DUTIES AND RESPONSIBILITIES:

Under the direction of the Medicaid Fraud Control Unit Chief, assists in healthcare investigations by: reviewing provider and recipient records, by making determinations of medical necessity, by making determinations as to whether services were provided and properly documented, and by making determinations as to whether proper diagnostic and procedure codes were used in submitting claims to the New Jersey Medicaid Program. Maintains a comprehensive understanding of current policies and procedures of the New Jersey Medicaid Program. Participates as a member of an interdisciplinary team in healthcare fraud, and patient abuse and neglect investigations, and provides support to members of other disciplines in such investigations. Participates in interviews of subjects and witnesses, and prepares written summaries of such interviews. Acts as a liaison for MFCU's state and federal partners, to attend meetings/conferences with various community organizations, and to perform community outreach. Prepares written reports of findings and opinions as directed by the Deputy Attorney General. May testify as a witness in grand jury and trial court proceedings.

•  Maintains a comprehensive knowledge of the policies and procedures of the New Jersey Medicaid Program.
•  Demonstrates thorough knowledge of and insures compliance with departmental policies and procedures governing the New Jersey Medicaid Program; state and federal laws and policies governing Medicare and Medicaid.
•  Applies appropriate regulations, policies, and procedures to accurately determine reimbursable services and eligibility of providers as requested.
•  Assists Deputy Attorneys General in healthcare fraud and patient abuse and neglect investigations by reviewing provider and patient records.
•  Makes determination of medical necessity, quality of services, and appropriateness of services rendered based on chart review and client interview and assessment.
•  Maintains a current repository of medically related information and departmental policies and procedures specific to the target groups reviewed.
•  Documents non-compliance with Departmental, Federal and State policies and procedures and current standards and practices of medical documentation monitoring activities.
•  Reviews medical/clinical records for meeting criteria for authorized services.
•  Leads investigations as a member of an interdisciplinary team.
•  Determines records to be reviewed.
•  Directs the review of records appropriate to each program and provider audited.
•  Determines program compliance and deficiencies according to established guidelines.
•  Makes assignments and provides immediate feedback to civil investigatory staff regarding any blatant compliance issues.
•  Accurately documents findings from audit on standard forms.
•  Participates in interviews of subjects and witnesses, and prepares written summaries of such interviews.
•  Prepares written reports of findings and opinions.
•  May testify as a witness in grand jury and trial court proceedings.

Skills

REQUIRED QUALIFICATIONS:

•  Current RN license in the State of New Jersey
•  Graduation from an accredited college or university with a Bachelor’s degree.
•  Five (5) years of experience in the conduct of civil or criminal investigations related to compliance, enforcement, detection, and surveillance activity, including the preparation of investigative reports.
•  OR Five (5) years of experience in the conduct of investigative administrative audits and/or regulatory examinations of records maintained by businesses and organizations.
•  OR Five (5) years of experience in the conduct of investigations for the government, the military, consumer protection programs, public advocacy organizations, or the public interest.
•  AND two (2) years of the five (5) years of experience shall have been in a team leader or lead investigator capacity.
•  

Preferred Qualifications:

Experience in one or more of the following:
1) Experience in the analysis of medical services documentation and related claims
2) Utilization Review
3) Case Management
4) Analysis of CPT codes and/or ICD-10 Diagnosis Codes
5) Medical Billing.

OTHER KEY FACTORS:

•  Applicants who do not possess the required education may substitute experience as indicated on a year-for-year basis.
•  A Juris Doctorate degree or a Master’s Degree in Criminal Justice, Public Administration, Business Administration, Law, or a related field may be substituted for one (1) year of the non-supervisory experience.
•  Appointees will be required to possess a driver's license valid in New Jersey if the operation of a vehicle, rather than employee mobility, is required to perform the essential duties of the position.
•  All offers of employment are conditional subject to the applicant agreeing to and then passing a background check that may include fingerprinting.

Notes

BENEFITS:

•  Paid Leave Time
•  Paid State Holidays
•  Health, Dental, Vision and Prescription Benefits
•  Life Insurance, Deferred Compensation and Retirement Plans
•  Telework may be available

HOW TO APPLY: If qualified, please send a cover letter indicating interest in job vacancy announcement #23-584 with a copy of your valid NJ RN license and a current resume to the Recruitment Coordinator at [email protected] on or before the closing date of November 11, 2023.

The “New Jersey First Act,” N.J.S.A. 52:14-7 (L. 2011, Chapter 70), requires new public employees to reside in the State of New Jersey within one (1) year of employment.

The Department of Law and Public Safety is an Equal Opportunity Employer and is committed to inclusive hiring and dedicated to diversity in our staff. We strongly encourage people from all groups and communities to apply.

For more information, please visit https://www.njoag.gov/careers/all-job-postings/


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