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Attorney III, Criminal, Medicaid Investigations

State of North Carolina Wake County, NC
medicaid fraud health health care fraud legal providers medical justice attorneys federal court regulations funds
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Description of Work

THE STARTING SALARY FOR A NEW HIRE TO THIS POSITION IS LIMITED TO THE RECRUITMENT RANGE OF  $ 84,728 to $ 90,799.  Salary offers for the selected candidate are based on the candidate's education and experience related to the position, as well as our agency budget and equity.

The North Carolina Department of Justice, led by the Attorney General of North Carolina, represents the State of North Carolina in court and provides legal advice and representation to most state government departments, agencies, officers, and commissions. The Department also represents the State in criminal appeals from state trial courts, and brings legal actions on behalf of the state and its citizens when the public interest is at stake.

This position is not-subject to the Fair Labor Standards Act.

This position is located in the Medicaid Investigations Division of the Department of Justice.  The Attorney General's Medicaid Investigations Division investigates and prosecutes health care fraud committed by Medicaid providers and the physical abuse of patients and embezzlement of patient funds in Medicaid-funded facilities. These cases protect and recover taxpayers dollars that can be used to provide needed medical services to Medicaid enrollees.  These cases also protect our most vulnerable elderly and disabled citizens.

The Medicaid Investigations Division receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $6,348,028 for Federal fiscal year (FY) 2021. The remaining 25 percent, totaling $2,116,008 for FY 2021, is funded by the State of North Carolina.


Our Medicaid Investigations Division (MID) is staffed by Department of Justice attorneys, investigators, auditors, analysts, and a nurse investigator, paralegals, and administrative staff.  MID provides state and national training opportunities to aid employees in understanding the complexities of health care fraud investigations.  Cases are tried in state and federal court in partnership with law enforcement agents with federal and state agencies such the Office of Inspector General, FBI, IRS, NC SBI, Sheriffs' Offices, and Police Departments.

Over the past decade, the NC MID has recovered more than $20 million per year for the past three years and helped win more than 450 criminal convictions in health care fraud and abuse cases.

The Attorney General's office and the Medicaid Investigations Division are committed to ending Health Care Fraud. The link below is provided for your information.
https://www.ncdoj.gov/Top-Issues/Stop-Health-Fraud-(1).aspx

The Criminal Section conducts investigations and brings state and federal actions against Medicaid providers alleged to have committed complex health care fraud schemes.
 

The primary purpose of the Criminal Enforcement Attorney position is to prosecute criminal cases and assist with criminal investigations. The criminal cases involve Medicaid fraud, patient abuse, and/or misappropriation of patient funds. The Criminal Section will bring state and federal actions against Medicaid providers alleged to have committed complex health care fraud schemes. The Criminal Enforcement Attorney position is also one of the attorney positions that fulfills the staff requirements of a MFCU contained in Title 42 of the Code of Federal Regulations, Section 1007.13(a)(1), which mandates that the MFCU staff must include "one or more attorneys experienced in the investigation or prosecution of civil fraud or criminal cases, who are capable of giving informed advice in applicable law and procedures and providing effective prosecution or liaison with other prosecutors."

The allegations investigated include the submission of fraudulent claims to the Medicaid Program for services or supplies not rendered, billing for a higher level of service than was actually provided, double billing, soliciting or paying kickbacks, billing for a service the provider knows is not medically necessary, and cost report fraud. Allegations investigated also include patient abuse and neglect and the misappropriation of patient funds.

Duties include:


  • Thoroughly review all pertinent information relating to cases referred to the Division or generated by the Division.
  • Ensure investigations are conducted within the parameters and in accordance with current state and federal laws and court rulings which are often complicated and technical in nature.
  • Determine whether there is a criminal violation of the law by thorough and precise analysis, research of documentary evidence, and¬†interviews.
  • Analyze, review and prepare state and federal arrest warrants, indictments, and other pleadings necessary to the successful prosecution of charges initiated by the Division.
  • Supervise the preparation of cases being presented in state or federal court.
  • Work with investigators to investigate cases and gather sufficient evidence¬†to support the filing of a state or federal indictment or warrant,
  • Prepare discovery and analyze and respond to discovery requests, and ensure that all discovery is provided as required by law.
  • Perform legal research in the field of health care fraud and investigations including precedent setting arguments.
  • Organize trial¬†documents to insure their admissibility and to make them understandable to the court and jury.
  • Pursue cases in state court as a Special Prosecutor or in federal court as a¬†SAUSA¬†or may pursue the case jointly in state or federal court with Assistant District Attorneys or Assistant United States Attorneys.
  • Negotiate criminal pleas in complex criminal actions, prepare agreements for criminal restitution, and analyze financial settlements proposed by opposing counsel.
  • Pursue and assist in the recovery of damages and penalties from Medicaid providers who have committed fraud by bringing and supporting state and federal forfeiture proceedings.
  • Lead parallel criminal actions and provide direction to the investigators on the criminal aspects of the matter.
  • Provide consultation and advice to the Criminal Chief and Director; keep the Director and Criminal Chief apprised of important developments in criminal cases.
This position requires travel which may include overnight stays.
This position requires some overtime.

Knowledge, Skills and Abilities / Competencies

  • Ability to effectively bring and supervise complex investigations of fraud by providers of medical assistance under the state Medicaid Program and other health care programs.
  • Thorough knowledge of laws and regulations pertaining to health care, particularly those relating to the Medicaid program.
  • Thorough knowledge of rules and regulations pertaining to Medicaid reimbursement and considerable knowledge of the administrative operation of health care facilities and professional medical offices and the ability to deal effectively with management and employees of these organizations.
  • Working knowledge of the federal and state criminal laws relating to fraud by health care providers.
  • Thorough knowledge of accounting and auditing principles and practices.
  • Thorough knowledge of the legal principles and techniques of conducting criminal investigations.
  • Thorough knowledge of state and federal forfeiture actions.
  • Ability to examine and analyze all types of medical and business records, and present the findings to courts and juries orally and in writing to reveal in a clear and orderly manner and the legal position of the Division in the interpretation of complex statutes and regulations.
  • Working knowledge of criminal health care fraud and the ability to recognize matters initially referred to the Division for civil action that should be investigated to determine whether a criminal health care fraud offense has been committed.
  • Ability to communicate effectively on medical and financial matters before a court and jury,
  • Ability to effectively utilize and direct medical consultants in reviews of the practices of medical providers,
  • Ability to maintain an effective working relationship with judges, related federal and state agencies and administrators, and other legal and administrative staff within the Department of Justice, and the general public.
  • Able to satisfactorily complete a detailed federal agency national security personal background investigation in order to become eligible for appointment as a SAUSA.

Minimum Education and Experience Requirements

Licensed to practice law by the North Carolina State Bar and three years of progressively responsible professional legal experience. NOTE: GS 114-2 and 114-6 make it the duty of the Attorney General of NC to represent the State of North Carolina in all litigation unless another statute specifically states otherwise.

Supplemental and Contact Information

Computer literacy is an important component of all DOJ jobs, we encourage you to apply electronically. All applicants must complete and submit a State application for employment using the NEOGOV Online Job Application System (http://www.oshr.nc.gov/jobs/) for the State of North Carolina.

To receive credit for your work history and credentials, you must list the information on the online application form. Any information not included on the application form cannot be considered for qualifying credit. Embedded or attached resumes are not accepted as a substitution for a completed application.

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