Investigator VI Performs advanced administrative investigative work which involves researching, reviewing and investigating fraud, waste and abuse of providers enrolled in various Medicaid programs. The work involves investigation, evaluating and analyzing data from ad hoc query reports and detection systems; planning and organizing, being familiar with multiple Medicaid programs; collecting and analyzing evidence; utilizing searches of databases and websites to obtain relevant case information; reviewing contracts and financial records; interviewing and taking sworn affidavits; preparing case documents and investigative case summaries and testifying in administrative hearings or judicial proceedings. The investigator may be required to participate in meetings on policy and procedures; and/or interpret program policies, standards and procedures for various state and federal agencies. In addition, this position performs other duties as assigned and is required to maintain unit operations. The investigator works under limited supervision of the Medicaid Provider Integrity [MPI] Manager with considerable latitude for the use of initiative and independent judgment. May plan, assign, and supervise the work of others. Work involves up to 50% travel.
Essential Job Functions:
1. Conducts investigations of alleged Medicaid provider fraud, waste, program abuse and historical non-compliance. Researches, reviews, and investigates advanced complaints and cases. Examines, investigates, evaluates and analyzes the business and claims activity of entities to ensure compliance with statutory standards and regulations. Performs detailed records reviews as required. Develops cases and testifies and presents evidence in informal reviews and judicial proceedings as needed (35%).
2. Evaluates and summarizes investigative findings. Prepares a detailed, comprehensive and grammatically correct Case Summary or Closure Memorandum for each assigned case written according to Office of Inspector General [OIG], Medicaid Provider Integrity [MPI] policies and procedures (10%).
3. Effectively communicates investigative findings to the MPI Manager, Director of MPI, other Health and Human Services Commission (HHSC) staff, external agencies and before administrative, civil and criminal courts if needed (10%).
4. Develops witness lists and comprehensive exhibits to ensure effective case presentation during informal reviews and court cases. Testifies and presents evidence in informal reviews and judicial proceedings (before administrative, civil and criminal courts) as needed (10%).
5. Contacts and interviews recipients, witnesses, providers, complainants and providers' staff regarding investigations (10%).
6. Interprets and applies applicable agency, state and federal policies, procedures, rules and regulations (5%).
7. Makes, establishes and maintains liaison through consultative visits and contacts with the Attorney General's Medicaid Fraud Control Unit (AGMFCU), Licensure Boards, Department of Aging and Disability Services (DADS), Department of State Health Services (DSHS), State District Attorney's Offices, U.S. Attorney's Offices, organizations, associations, groups and other state/federal agencies to discuss Medicaid provider fraud, waste and abuse investigations, interpret program policies, standards and procedures, conduct training workshops, participate in joint investigations, and provide advice and recommendations (5%).
8. Recommends improvements, changes, or modifications to program policies, procedures, rules and regulations to detect and prevent Medicaid program fraud, waste and abuse (5%).
9. Assists with developing and conducting training. Mentors and assists co-workers and staff from other OIG divisions and HHSC Enterprise agencies, when appropriate and as needed. Assists with developing and preparing appropriate training and operational manuals, educational materials, and information, when appropriate and as needed (5%).
10. Performs other duties as assigned or required to maintain division operations (5%).
Knowledge Skills Abilities:
a. Knowledge of investigative principles, techniques, and procedures; of the laws governing the activities regulated by the agency; and of court procedures, practices, and rules of evidence.
b. Knowledge of Medicaid program policies and procedures and knowledge of fraud and abuse rules and regulations. Ability to understand, interpret, and appropriately apply policies, procedures, rules and regulations.
c. Ability to plan, organize, and conduct investigations, surveys, inspections, and examinations; to conduct interviews and gather facts; to evaluate findings and prepare concise reports; and to testify under pressure in hearings and court proceedings.
d. Ability to communicate effectively both orally and in writing.
e. Ability to establish and maintain effective working relationships with supervisory personnel, co-workers, providers, attorneys and individuals from other state and federal agencies and boards.
f. Ability to use personal computers and related software. Word, Excel, FICO Insurance Fraud Manager and Access preferred.
g. Ability to prioritize tasks; work under time constraints and under minimal supervision; and to plan, assign and/or supervise the work of others.
Registration or Licensure Requirements:
Initial Selection Criteria:
1. Graduation from an accredited four-year college or university. May substitute full-time investigative, white-collar crime, auditing, accounting, Medicaid/Medicare program provider compliance monitoring, healthcare insurance, or closely related experience for required education on a year for year basis.
2. Five years of full time investigations, auditing, accounting; Medicaid/Medicare program provider compliance monitoring; white collar crime investigations; legal experience in healthcare insurance or similar experience. May substitute a juris doctorate or Criminal Justice degree.
3. Experience using word processing and electronic spreadsheet applications.
Preferred: Knowledge of sampling tools; statistical sampling and extrapolations.
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.