Investigator VI

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Job Description:  

This position is housed within the Provider Field Investigations (PFI), Medicaid Program Integrity unit of the Investigations & Utilization Reviews (I&UR) division of the Office of Inspector General (OIG) and reports directly to a PFI Manager. Performs administrative investigations of Medicaid providers and non-providers involving allegations of fraud, waste and/or abuse in the provision and delivery of all health and human services in the state. This role requires interviewing skills, extensive research & data analysis, and the development of complex investigative reports. Work involves up to 25% statewide travel, which includes some overnight travel. The investigator works under limited supervision of the PFI Manager with considerable latitude for the use of initiative and independent judgment.

Essential Job Functions:

Researches, reviews, and objectively investigates advanced complaints, referrals and self-initiated cases alleging Medicaid provider fraud, waste, and/or abuse. Interprets and applies applicable agency, state and federal policies, procedures, rules, and regulations. Performs timely investigative duties associated with investigations in conformity with applicable PFI policies and procedures, including but not limited to case-specific deadlines assigned by management. Obtains approval from Deputy Inspector General for MPI or designee to timely complete all assigned and/or self-initiated investigations. Gathers, analyzes, and interprets business, financial, and medical documentation. (35%)

Evaluates, summarizes, and communicates investigative findings through various oral and written communications. Prepares detailed, comprehensive, and grammatically correct case summaries for each assigned case. Performs timely administrative duties associated with investigations in conformity with applicable PFI policies and procedures, including but not limited to investigative timelines. (15%)

Conducts professional interviews with recipients, witnesses, providers, complainants, and provider’s staff regarding investigations. (10%)

Develops comprehensive exhibits, including but not limited to a schedule of incorrect claims, to ensure effective case presentations in administrative hearing and court cases, when required. Testifies and presents evidence in informal reviews and judicial proceedings (before administrative, civil, and criminal courts) as needed. (15%)

Effectively communicates findings to the PFI Manager, PFI Director, Deputy Inspector General for MPI, other agency staff, and external entities. Provides testimony and presents evidence in formal hearings and court proceedings; develops and presents criminal fraud cases to criminal investigators and prosecutors, when appropriate. (10%)

Makes consultative visits and establishes liaisons with the Attorney General’s Medicaid Fraud Control Unit, the Healthcare Program Enforcement Division, Managed Care Organizations (MCOs) other state and federal agencies, licensure boards, and other external entities to discuss and/or coordinate Medicaid provider fraud and abuse investigations; interpret program policies, standards, and procedures; conduct training workshops; participate in joint investigations and provide advice and recommendations. (5%)

Develops, recommends, and implements solutions to problems. Reviews, develops, and recommends guidelines, procedures, policies, rules, and regulations to detect and prevent Medicaid fraud, waste, and program abuse. Self-initiates cases or projects designed to generate cases to prevent, detect and investigate fraud, waste and abuse not reported through the referral or MPI Intake process. (5%)

Performs other duties as assigned or required to maintain division operation. Keeps manager informed as required or as necessary.   (5%).

Knowledge, Skills & Abilities: 

1. 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.
2. Knowledge of Medicaid program policies and procedures and knowledge of fraud and abuse rules and regulations.
3. Ability to understand, interpret, and appropriately apply policies, procedures, rules and regulations.
4. Ability to plan, organize, and conduct investigations; to conduct interviews and gather facts; to evaluate findings and prepare complex, concise reports; and to testify in hearings and court proceedings.
5. Ability to communicate effectively both orally and in writing.
6. Ability to establish and maintain effective, professional working relationships with supervisory personnel, co-workers, providers, attorneys and individuals from other state and federal agencies and boards.
7. Ability to use personal computers and related software, to include the ability to analyze complex queries using advanced functions and formulas in Microsoft Excel to develop reports, pivot tables, and graphs; and ability to prepare correspondence using Microsoft Word to respond to requests and document investigative findings.
8. Ability to prioritize tasks; work under time constraints and under minimal supervision.
9. Ability to travel up to 25% of the time, to include statewide and/or overnight travel.
10. Performs other duties, as assigned.

Initial Screening Criteria:  

Requirement #1:Graduation from a four-year college or university, which culminated in a bachelor’s degree;

    OR

Requirement #1: Four years of specialized experience, as defined below, may be substituted for the required education on a year-for-year basis. (NOTE: Any year of specialized experienced counted towards Requirement #1 must be in addition to the two years of specialized experience qualified for Requirement #2, below.)

    OR

Requirement #1: Any combination of years of education and specialized experience, as defined below, that total six. (NOTE: Any year of specialized experienced counted towards Requirement #1 must be in addition to the two years of specialized experience qualified for Requirement #2, below.)

     AND

Requirement #2: Two years of specialized experience in any of the following areas: investigations, audits, accounting, public policy, healthcare administration, contract monitoring, legal work, Texas Medicaid program experience and/or healthcare compliance monitoring in Medicaid or Medicare, Managed Care Organizations (MCO), Dental Maintenance Organizations (DMO), and/or Dental Service Organizations (DSO).

Preferred (not required) Registrations, Licenses, Certifications and/or Skills:

• Certified Fraud Examiner (CFE)
• Accredited Healthcare Fraud Investigator (AHFI)
• Juris Doctorate (JD)
• Registered Nurse (RN)
• Licensed Professional Counselor (LPC)
• Certified Internal Auditor (CIA)
• Registered Dental Hygienist (RDH)
• Certified Pharmacy Technician (CPhT)
• Licensed Clinical Social Worker (LCSW)
• Graduate Degree in Public Administration, Public Health or Public Policy (or similar)
• Bilingual in English/Spanish
• Experience with Business Objects and/or PI Case Tracker software

Registrations, Licensure Requirements or Certifications:    N/A

Additional Information:  

The OIG is responsible for preventing, detecting, auditing, inspecting, reviewing, and investigating fraud, waste, and abuse in the provision of HHS in Medicaid and other HHS programs. Potential employees of OIG are subject to criminal background checks in accordance with the HHS Human Resources policy. Selected applicants must complete a national fingerprint-based criminal background check through the Texas Department of Public Safety (TDPS) and Federal Bureau of Investigations (FBI) to determine if they have criminal history record information that constitutes a bar to employment.

Any employment offer is contingent upon available budgeted funds. The offered salary will be determined in accordance with budgetary limits and the requirements of HHSC Human Resources Manual. State budget limits typically result in this position being filled in the lower end of the listed salary range.

HHS agencies use E-Verify. You must bring your I-9 documentation with you on your first day of work.

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.

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Active Duty, Military, Reservists, Guardsmen, and Veterans:

Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to those listed in this posting. All active-duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information please see the Texas State Auditor’s Job Descriptions, Military Crosswalk and Military Crosswalk Guide at Texas State Auditor's Office - Job Descriptions.

ADA Accommodations:

In compliance with the Americans with Disabilities Act (ADA), HHSC and DSHS 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.

Pre-Employment Checks and Work Eligibility:

Depending on the program area and position requirements, applicants selected for hire may be required to pass background and other due diligence checks.

HHSC uses E-Verify. You must bring your I-9 documentation with you on your first day of work. Download the I-9 Form

Telework Disclaimer:

This position may be eligible for telework.  Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business needs.