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Series established January 3, 2001
This series specification describes the three classifications used by the Department of Health Services to detect and prevent fraudulent business practices being committed by health care-related service and supply entities against government-funded programs.
Under general direction, incumbents in this class series perform sensitive and complex fraud detection reviews of multiple provider types including, but not limited to: physicians, pharmacies, clinical laboratories, medical suppliers, orthotists, podiatrists, adult day health centers, and nonemergency medical transportation providers; and promote prevention of billing fraud by educating providers on the consequences of committing fraud against government-funded health care-related service programs.
Incumbents in this class series develop field-based fraud risk assessment surveys designed to rate the providers, statewide, by level of potential for fraud, apply surveys to the providers to determine which providers demonstrate the most potential for fraud, and perform investigative reviews of those providers.
Due to the investigative nature of the reviews performed by this class series, the incumbents are required to analyze each case to determine what review method or methods are appropriate for that case.
Investigative reviews for the Department of Health Services will include analysis of business practices and claim patterns, investigative follow-up reviews to detect and document evidence of diverted and/or missing assets, material deceits, false claims, and/or acts of concealment. The incumbent then prepares a written report of the review findings which includes any recommended administrative sanctions, and any basis for criminal prosecution referrals to appropriate law enforcement agencies, if applicable. In the case of any administrative action or in the case of a criminal prosecution, the incumbent may be called upon to testify at depositions and in court.
The number and level of subordinate staff, scope and consequence of decisions made, degree or program and policy involvement, sensitivity and complexity of work assignments, independence of action, and size, fiscal impact, and nature of reviews.
This is the entry and full journey level in this series. Under general direction, incumbents apply specialized laws and investigative procedures to complete fraud detection and prevention field reviews independently or as part of a multiagency task force. The sensitive and complex nature of these reviews require the highest degree of judgment, knowledge, and ability to distinguish evidence of financial deceit or concealment from honest mistakes or simple oversight errors and be able to effectively communicate the review findings.
This is the supervisory level in the series. Under general direction, incumbents supervise a unit of Fraud Prevention Specialists performing fraud detection and prevention field reviews in a geographic area. This is a working supervisor that may be called upon to perform field reviews.
This is the management level with responsibility for carrying out policy directives and managing the investigative review activities through subordinate supervisors on a geographic basis.
Education: The following education is required when Pattern II is used to qualify at all levels of the class series.
Education: Equivalent to graduation from college with a specialization in Accounting. (Registration as a senior student in a recognized institution will admit applicants to the examination, but they must produce evidence of successful completion of the curriculum and the prescribed courses before they may be considered eligible for appointment.)
Education: Completion of a prescribed professional accounting curriculum given by a residence or correspondence school of accountancy, including courses in elementary and advanced accounting, auditing, cost accounting, and business law.
Education: Completion of the equivalent of 19 semester hours of course work, including 16 semester hours of professional accounting courses given by a collegiate-grade residence institution including courses in elementary and advanced accounting, auditing and cost accounting, and three semester hours of business law. (Persons who will complete work requirements outlined under Pattern II and III above during the current quarter or semester will be admitted to the examination, but they must produce evidence of successful completion of the curriculum and the prescribed courses before they may be considered eligible for appointment.)
Experience: One year of experience in the California state service performing investigative reviews of a complex or sensitive nature in a class with a level of responsibility equivalent to a Health Program Auditor III or a Senior Special Investigator.
Experience: Four years of increasingly responsible professional experience performing financial audits or examinations of a complex or sensitive nature, with duties related to the detection and prevention of fraudulent business practices being committed by health care-related service entities against government-funded programs.
Experience: One year of experience in the California state service performing the duties of a Fraud Prevention Specialist or performing the duties of a class with a level of responsibility equivalent to that of a Health Program Auditor IV or Health Program Audit Manager I.
Experience: Five years of increasingly responsible professional experience performing investigative financial audits or examinations of a complex or sensitive nature, involving duties related to the detection and prevention of fraudulent business practices being committed by health care-related service entities against government-funded programs. (Experience in the California state service applied toward this requirement must include at least two years performing the duties of a class with a level of responsibility equivalent to that of a Fraud Prevention Specialist.)
Experience: One year of experience in the California state service performing the duties of a Supervising Fraud Prevention Specialist I or performing the duties of a class with a level of responsibility equivalent to that of a Health Program Audit Manager II.
Experience: More than five years of increasingly responsible professional experience performing investigative financial audits or examinations of a complex or sensitive nature, involving duties related to the detection and prevention of fraudulent business practices by health care-related service entities against government-funded programs, including at least two years supervising staff responsible for performing such reviews. (Experience in the California state service applied toward this requirement must include at least two years performing the duties of a class with a level of responsibility equivalent to that of a Supervising Fraud Prevention Specialist I.)
Knowledge of: General auditing and accounting principles, practices, procedures, and terminology; business law; State and Federal laws and regulations which regulate the use of government-funded programs; legal opinions and court decisions as they relate to the use of government-funded programs; principles, practices, techniques, and trends in fraud detection and prevention including: mail and financial fraud scheme methodologies; cash transaction analysis; hidden asset tracing; external verification procedures; principles of civil and criminal law; electronic data processing systems analysis and data mining; investigative interview techniques; best evidence collection and preservation techniques; protocol for civil and criminal court proceedings.
Ability to: Perform reviews while applying financial fraud laws and regulations in sensitive settings and with minimal supervision; review, analyze, and articulate systemic fraud indicators and evidence of fraud in accounting records and financial business practices; review management and other related controls over financial data; effectively mine and analyze computerized billing and claiming data for irregular patterns; reason logically and creatively in unique situations; conduct effective fact-finding interviews; establish and maintain cooperative relationships with those contacted during the course of the investigative reviews; analyze, organize, and effectively communicate findings and administrative recommendations; testify at depositions and court hearings; serve as an expert witness in civil or criminal fraud cases.
Knowledge of: All of the above, and principles, practices, and trends of government and business administration; principles and techniques of personnel management and supervision (the supervisor's role in equal employment opportunity, disciplinary guidelines and personnel rules, prevention of discrimination and harassment in the workplace, and maintaining a safe work environment); applicable collective bargaining memorandum of understanding and related issues; State and Departmental policies and procedures; protocol for establishing and maintaining cooperative relations with other Department of Health Services' units and outside investigative agencies.
Ability to: All of the above, and carry out Department of Health Services' policies and procedures; plan, organize, and direct fraud detection and prevention programs within required time frames; budget and allocate resources to achieve Department of Health Services' program goals and objectives; effectively supervise a unit of Fraud Prevention Specialists and other personnel; initiate and review personnel matters; effectively contribute to establishing equal promotional opportunity and staff development; provide effective communication between staff and management; promote and maintain professional goodwill and confidence.
Knowledge of: All of the above, and techniques and methods for managing specialized and sensitive investigative programs; the Department of Health Services' mission statements, policies, directives, and time lines; legislature and outside agency protocols; training and other resources available from other Department of Health Services' units and outside agencies; functions, roles, relationships, and responsibilities of other Department of Health Services' audit and investigative units and outside agencies; a manager's responsibility in promoting equal opportunity in hiring and employee development.
Ability to: Perform all of the above, in addition to plan, direct, and, in all respects, manage fraud prevention program resources, including supervisory and support personnel, in accordance with Department of Health Services' policies, budget allocations, and time lines; effectively direct and supervise the activities of supervisory and support staff; develop and maintain administrative and operational quality control measures; develop, implement, and evaluate training programs or projects; effectively promote and otherwise ensure compliance with equal opportunity and safe workplace laws.
All incumbents must possess a valid driver license. In addition, incumbents must be willing to travel to perform duties at various sites and work irregular hours as required by investigative audit.