Special Agent (BWC Fraud Investigator) - Healthcare Provider Team
BWC PN 20066717
This position is located in Cincinnati (Hamilton County), Ohio.
Pay Range: OCSEA/AFSCME 32
The Bureau of Workers' Compensation (BWC) is a dynamic organization that offers career opportunities across many different disciplines. Please click this link to read more, then come back to this job posting to submit your application!
This position shall be filled in accordance with the provisions of the OCSEA Collective Bargaining Agreement. BWC bargaining unit members have selection rights before non-bargaining unit members. All other applications will only be considered if an internal bargaining unit applicant is not selected for this position.
Under general supervision of the BWC Special Investigations Supervisor, independently, or as lead investigator or as a member of an investigations team, analyzes computerized data (e.g. Human Services Criss-E, Auto Track, Sanctions, Ohio Offender, BMV photo files, LEADS-Law Enforcement Automated Data System) to detect fraudulent activity: conducts field &/or in-house investigations into allegations of fraud, abuse &/or other violations (e.g. felony & misdemeanor criminal activity, administrative or ethical misconduct) against the Ohio Bureau of Worker's Compensation (e.g.
OBWC) system by healthcare providers, medical professionals, injured workers, & any other person(s) or entity(ies) involved in allegations of fraudulent activity; evaluates referred allegations to determine existence &/or extent of fraudulent activity as defined by OBWC rules & laws; independently manages & prioritizes assigned investigative caseload; develops action plans deemed appropriate to successfully complete assigned cases; researches criminal & civil records at city, county, state & federal courthouses, licensing boards & regulatory bureaus; procures, audits & analyzes records (e.g. medical, payroll, bank account records, tax statements, employment records, personal & business records, applicable financial records) from employers, financial institutions, health care organizations, Ohio Department of Job & Family Services (JFS), other government agencies or other business entities as required by individual cases in order to gather evidence & documentation; researches, audits, analyzes & interprets medical & benefits documentation & terminology from internal OBWC claims, risk & provider files & computerized claims information (e.g. PowerSuite); obtains subpoenas; assigns search duties & reviews medical information (e.g. patient charts, billing records) for compliance with BWC policies for treatment for injured workers found in healthcare provider's office; locates, interviews & interrogates subjects of investigations to obtain statements, affidavits &/or confessions; contacts, interviews & documents other individuals (e.g. informants, witnesses, physicians, attorneys, victims) associated with allegations under investigation; collects & preserves all physical evidence (e.g. patient information from health care providers, payroll records, bank statements, tax records, suspect & witness statements) to support case findings & prepare concise, accurate & detailed investigative reports to prove or disprove allegation of fraudulent or criminal activity by health care providers &/or injured workers; reviews & updates BWC Fraud Management System (FMS). Independently, or as lead investigator or as team member, conducts covert surveillance activities in order to identify fraudulent activity by health care providers & injured workers: conducts random checks on residences &/or alleged work locations of suspects; conducts surveillance within & outside of Ohio; obtains undercover forms of identification to assist in maintaining undercover identity; formulates & decides cover stories to work best with ever changing circumstances; assesses immediate situations & makes split-second decisions as needed in order to maintain undercover identity; performs surveillance of dangerous & potentially violent individuals in hazardous areas to document criminal &/or fraudulent activity or behavior; determines best surveillance sites; operates sophisticated undercover & surveillance equipment (e.g. cameras, camcorders, mini-cameras, undercover audio recording devices, time-lapse VCRs, pinhole camera systems, two-way &/or other radio systems) in potentially dangerous situations &/or surroundings; maintains surveillance equipment by ensuring proper storage & use; troubleshoots malfunctions of surveillance equipment; carries & utilizes expandable baton/nightstick & chemical repellents (e.g. MACE/pepper spray) as necessary; procures trash from businesses & individuals to obtain evidence & develop additional leads.
Collects, inventories, secures & examines evidence: acts as team evidence custodian throughout course of investigations & ensures compliance with established evidence procedures; executes various legal actions (e.g. warrants & subpoenas); identifies patterns of abusive &/or manipulative billing schemes used by health care providers & calculates financial impact on State Insurance Fund; assists in making decisions regarding possible criminal prosecution & refers appropriate cases to Attorney General's office; testifies at Industrial Commission hearings & in courts of law; recommends policy & procedure changes (e.g. evidence handling & presentation, investigation safety, surveillance procedures, equipment needs, handling irate or dangerous suspects); operates personal computer (e.g. develops & maintains databases, creates & maintains spreadsheets to display evidence in sequential order, verifies claims management entries, enters all investigative activities in Fraud Management System [FMS], searches internet to locate resources, maintains confidential reports); coordinates investigations with appropriate local law enforcement agencies & Ohio State Patrol; submits forensic evidence for analysis; utilizes Law Enforcement Automated Data System (LEADS) & other related crime computer information systems (e.g. NCIC, CCH) through the Ohio State Highway Patrol; prepares video, audio & paper evidence exhibits for administrative hearings, grand juries, & criminal & civil proceedings. Serves as liaison with internal OBWC departments & external groups & agencies (e.g. local, state & federal law enforcement agencies, state regulatory boards & agencies [e.g.
Attorney General's office, Industrial Commission, Inspector General's office, Ethics Commission, OBWC claims management, OBWC accounts payable, county prosecutor's office; Federal Bureau of Investigation, Ohio Bureau of Criminal Investigations & Identification, Social Security Administration, JFS, Ohio Department of Rehabilitation & Correction, Ohio Pharmacy Board, Ohio Medical Board, Ohio Chiropractic Board]): testifies before grand juries, courts of law & administrative hearings as to validity & accuracy of techniques used to obtain administrative & criminal evidence; attends briefings & team meetings; attends internal & external training seminars (e.g. surveillance techniques, undercover operations, public records searches, Reid technique of interviewing & interrogation, computer crime, electronic crimes, self defense); participates in developing internal training programs for new investigative personnel; develops curriculum & conducts training seminars as assigned (e.g. Red Flag Training).
Unless required by legislation or union contract, starting salary will be set at the lowest rate of the salary range. In most cases successful employees will move up a step in the salary range within six months, with subsequent step increases occurring every year as supported by successful performance evaluation results.
Completion of associate core program in criminology, criminal justice, or law enforcement;
AND 18 mos. exp. in conducting criminal investigations.
Or equivalent of Minimum Class Qualifications For Employment noted above.
(Note: conducting criminal investigations is defined as performing field interviews & interrogation, field surveillance, field information & evidence gathering techniques while conducting investigations involving violations of criminal law [i.e., special emphasis on theft & fraud cases] as well as researching various administrative laws, policies & procedures related to commission of possible criminal offenses).
The final applicant accepted for this position must successfully pass state highway patrol personal background check prior to employment.
Note: Pursuant to Ohio Administrative Code Chapter 4501users of system shall adhere to policies & guidelines published in NCIC operating manual, CJIS security policy, LEADS operating manual, LEADS security policy, newsletters,
& administrative messages from LEADS, all of which are either available on ODPS/LEADS intranet or disseminated to LEADS agencies; pursuant to LEADS security policy state & national fingerprint-based record checks must be conducted within 30 days of initial employment or assignment of all personnel, including appropriate IT personnel, having access to LEADS, or to records storage areas containing CCH/II data; minimum check must include submission of both a State of Ohio BCI& I card & an FBI applicant fingerprint card; both completed applicant fingerprint cards must be submitted by employing agency to State of Ohio Bureau of Criminal Identification & Investigation for processing & forwarding to Federal Bureau of Investigation; record of this check must be kept by employing agency & made available to LEADS upon request; fingerprint card returned by Ohio BCI&I is sufficient documentation.
Pursuant to Ohio Administrative Code Chapter 4501 terminal agency shall conduct a complete background investigation of all terminal operators including, but not limited to: an applicant fingerprint card submission to BCI&I & FBI, an inquiry of state & national arrest & fugitive files; terminal agency is required to notify CTO of any applicant's criminal record; existence of a criminal record may result in denial of access.
Department Of Administrative Services, State Of Ohio