Investigator VI

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 involving allegations of fraud, waste and/or abuse in the provision and delivery of all health and human services in the state.

Enforces state law relating to these services. 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.

• As of the date of this job posting, PFI investigators currently serve on a 100% mobile work status, with the understanding that the classification of mobile work is subject to revert to a traditional on-site work or telework environment based upon agency needs and/or upon employee performance at any time. See additional information section below for more information on mobile work requirements.

Essential Job Functions:

Researches, reviews, and investigates advanced complaints and cases alleging Medicaid provider fraud, waste, and/or abuse and recommending action(s) as appropriate. 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 complete no fewer than five full-scale investigations per year. 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. (10%)

Conducts 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. (10%)

Effectively communicates findings to the PFI Manager, Deputy Inspector General for MPI, other HHSC staff, and external entities. Provides testimony and presents evidence in formal hearings and court proceedings; develops and presents criminal fraud cases to criminal prosecutors, when appropriate. (15%)

Makes consultative visits and establishes liaisons with the Attorney General's Medicaid Fraud Control Unit, the Antitrust and Civil Medicaid Fraud Division, 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%)

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%)

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

Knowledge Skills Abilities:

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.

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.

Ability to plan, organize, and conduct investigations, surveys, inspections, and examinations; to conduct interviews and gather facts; to evaluate findings and prepare complex, concise legal reports; and to testify in hearings and court proceedings.

Ability to communicate effectively both orally and in writing.

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.

Ability to use personal computers and related software, to include an intermediate level competency with MS Word and Excel.

Ability to prioritize tasks; work under time constraints and under minimal supervision.

Ability to work in a virtual environment with tools such as MS Teams, Zoom, WebEx and/or other similar platforms.

Ability to travel up to 25% of the time, to include statewide and/or overnight travel.

Medicaid Fraud Abuse and Detection System [MFADS], Business Objects and PI Case Tracker experience preferred.

Registration or Licensure Requirements:

N/A Initial Selection Criteria:

Graduation from a four-year college or university. Four years of experience may be substituted for the required education.

Two years of experience in investigations, white-collar crime investigations, auditing, accounting, Medicaid, Medicare, Healthcare compliance monitoring, Managed Care Organizations (MCO), Dental Maintenance Organizations (DMO), Public Policy or Health Administration, Contract management/interpretation/analysis, or Legal.

Experience using a computer and software such as Word and Excel.

Preferred:

• Certified Fraud Examiner (CFE)
• Accredited Healthcare Fraud Investigator (AHFI)
• Juris Doctorate (JD)
• Registered Nurse (RN)
• Licensed Professional Counselor (LPC)
• Certified Internal Auditor (CIA)
• Licensed Clinical Social Worker (LCSW)
• Graduate Degree in Public Administration, Public Health or Public Policy (or similar)
• Bilingual in English/Spanish

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.

OIG will request that all applicants considered for an interview provide responses to essay questions. Failure to respond to the request could disqualify an applicant from the interview process.

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.

This position requires the frequent development and completion of complex legal documents and reports. This position also requires extensive data analysis and familiarity in working with and manipulation of large amounts of data within Microsoft Excel. An in-basket test related to Excel utilization, data analysis and writing skills may be required following applicant interviews.

Mobile work refers to mandatory work arrangements in which an employee's officially assigned duties require frequent travel to client and/or provider locations. When the employee is not traveling to these locations, the employee performs regular work duties at his or her residence.

As such, applicants may be hired from any geographic area of the State of Texas where OIG has a physical office location with available space. If selected for this position, the closest OIG office to the applicant's residence will be reviewed for availability of space. Employees will be provided a workspace, which could include shared office or cubicle space.

In addition to performance of mobile investigative fieldwork, statewide travel (including overnight travel) to an HHSC office will be intermittently required to perform this role and to attend mandatory training.

Mobile workers will have a designated office location but may also have a shared desk space they can use at a remote business office location. Mobile workers are not included in the CAPPS telework registry. Mobile work is not optional, it is a requirement of a person's job.

Employees are responsible for providing the necessary infrastructure for working at home, including an office space that affords the employee with privacy to discuss confidential investigative information, office furnishings (desk, chair, lamps, etc.), and utilities (reliable internet, electricity, telephone). The agency will not reimburse for utilities, or any items purchased for use at home, including office supplies, internet service, or maintenance or repair of personally owned equipment. The agency will provide a laptop, two monitors and cellular phone. MOS Code:

31B, 31D, EOD, 401, 5819, 7S0X1

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

I-9 Form - Click here to download the I-9 form.

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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