Claims Investigator performs moderately complex investigative work in HHS programs. Ensures investigations are conducted and reported in compliance with law, agency policy, and professional standards. Conducts fraud investigations and collects evidence following guidelines in the Association of Inspectors General Principles and Standards for Offices of Inspectors General. Screens referrals, collects evidence including obtaining business records affidavits, and prepare case records for criminal investigations. Conduct examinations of alleged violations of laws, rules, and regulations; identifies contacts and potential witnesses; and contacts suspects, clients or collaterals to verify recipient case information. Prepares cases, presents evidence, and provides testimony in Administrative Disqualification Hearings and court proceedings. Investigates and establishes overpayment claims in the SNAP, TANF, Medicaid, MEPD, CHIP, WIC, and other HHS programs. May conduct covert EBT retailer trafficking investigations. Liaison with other states' investigation departments, state and federal prisons, and other state and federal agencies; interacts or exchanges information with various state or federal law enforcement organizations. Reviews and analyzes records and reports from multiple agency, state and federal databases to collect data and to determine fraud and program compliance. Assists in making training presentations to HHSC eligibility staff. May impose Intentional Program Violation Disqualifications and/or perform fraud hotline activities. Works under limited supervision with considerable latitude for the use of initiative and independent judgment.
Essential Job Functions:
(30%) 1.) Researches, collects evidence including business records affidavits, and examines case discrepancies through multiple agency, state and federal data match processes to determine fraud and program compliance. Liaison with other states' investigations departments, state and federal prisons, and other state and federal agencies; interacts and exchanges information with various state or federal law enforcement organizations. (25%) 2.) Conduct investigations and examinations of alleged violations of agency policies, laws, rules, and regulations; ensures investigation activities are conducted following guidelines in the Association of Inspectors General Principles and Standards for Offices of Inspector General; identifies contacts and potential witnesses; and contacts suspects, clients or collaterals in person (home/site visits), by mail, or by telephone to verify recipient case information. May perform undercover or surveillance work in EBT retailer trafficking investigations. (20%) 3.) Evaluates, summarizes, documents investigative findings, and prepares detailed investigative case reports; collects evidence and prepares case records for criminal investigations; calculates overpayments and establishes overpayment claims; and negotiates restitution agreements to recover unauthorized benefit payments.(15%) 4.) Prepares cases for presentation at administrative disqualification hearings, fair hearings or court to report client program violations by presenting testimony and evidence.(5%) 5.) Assists in making training presentations to HHSC eligibility staff and assists agency staff in preparing and presenting information to appropriate law enforcement agencies.(5%) 6.) Performs related work as assigned. May perform General Investigations Fraud Hotline activities and/or impose Intentional Program Violation disqualifications in automated systems.
Knowledge Skills Abilities:
Knowledge of investigative principles, techniques, and procedures.Knowledge of office management and administrative procedures of the agency. Knowledge of court procedures, practices, and rules of evidence. Knowledge of state and federal laws, regulations, and policies related to health and human services. Knowledge of HHS social services programs. Skill in communicating effectively both orally and in writing. Skill in conducting legal research and analysis. Skill in developing sources of information. Skill in the operations of technical equipment and detection devices. Ability to plan, organize and conduct investigations. Ability to conduct interviews and gather facts. Ability to interpret and apply laws and regulations. Ability to compile, evaluate, and present information relevant to investigations. Ability to assess situations encountered during an investigation and take appropriate actions. Ability to comprehend agency policies and guidelines and determine employee, provider, or recipient compliance. Ability to testify in hearings and court proceedings. Ability to conduct diverse investigations with a minimum of supervision.
Registration or Licensure Requirements:
Initial Selection Criteria:
Graduation from an accredited high school or GED plus two years of current experience (within last three years) in applying SNAP, TANF, WIC and/or Medicaid policies, procedures, and regulations. - OR - College degree in business administration, criminal justice, or related field. -OR- Extensive investigative experience, including minimum three years working full time in a job that required gathering evidence, writing investigative reports, and being prepared to testify at hearings/trials.
Must be willing to travel 20% of the time. Must be willing to work overtime as needed. Works with automated systems. Must be able to type. Knowledge of Word and Excel is preferred.
In compliance with the Americans with Disabilities Act (ADA), HHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the on-line application, contact the HHS Employee Service Center at 1-888-894-4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview.