Performs highly advanced specialized and oversight (senior-level) investigative work which involves researching, reviewing and investigating Medicaid fraud, waste and program abuse cases and complaints; analyzing detection systems; developing methodologies for detection and evaluation; analyzing and interpreting business, financial and medical documentation; participating in meetings on policy and procedures; applying/interpreting program policies, standards and procedures; and coordinating investigative activities with other Office of Inspector General [OIG] divisions, the Office of the Attorney General [OAG], federal law enforcement agencies, state licensure boards, and/or other external entities. Provides testimony and presents evidence in formal hearings and/or court proceedings, when required. Advises, coordinates, and leads investigative teams. Assists investigators with developing fraud, abuse and/or waste cases. Assists with the development of guidelines, procedures and policies for conducting investigations to enhance and improve the results of investigative activities and division operations. May plan, assign, and/or supervise the work of others. Performs other duties as assigned and required to maintain unit operations. Works under minimal supervision with extensive latitude for the use of initiative and independent judgment. Work involves up to 50% travel; work hours other than 8AM to 5PM. Work involves viewing computer screens for long periods of time.
1. Researches, reviews, investigates and oversees the investigation of highly advanced complaints and cases alleging Medicaid provider fraud, waste, and/or abuse recommending action(s) as appropriate. Gathers, analyzes and interprets business, financial and medical documentation. Advises, coordinates and leads investigative teams. Advises, coordinates, and leads investigative teams with developing fraud, abuse, and/or waste cases (35%). 2. 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 Medicaid Provider Integrity [MPI]-OIG policies and procedures (10%). 3. Conducts interviews with recipients, witnesses, providers, complainants and provider’s staff regarding investigations (10%). 4. Develops witness lists and comprehensive exhibits to ensure effective case presentations in administrative hearing and court cases, when required (10%). 5. Effectively communicates findings to the Manager of Investigations, Director of 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 (10%). 6. Makes consultative visits to 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%). 7. 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 (5%). 8. Ensures the development of effective procedures for conducting investigations. Reviews and modifies administrative and technical policies and procedures and investigative techniques as appropriate. Periodically reviews samples of completed cases to ensure the consistent and correct application of policy (5%). 9. Assists in the development and training of staff and with monitoring the quality and quantity of investigations; oversees the implementation and methodology of training; reviews and modifies and prepares appropriate training, operational manuals, educational materials, and information (5%). 10. Performs other duties as assigned or required to maintain division operation (5%).
Knowledge of investigative principals, techniques, and procedures; of the laws governing the activities regulated by the agency; and of court procedures, practices, and rules of evidence. Extensive 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. Skills in planning, assigning and/ or leading/supervising the work of others. Skills in planning, organizing, and conducting fraud and abuse investigations, surveys, inspections, and examinations; interpreting and applying laws and regulations; conducting interviews and gathering facts; evaluating findings and developing cases and exhibits. Skills in communicating effectively both orally and in writing, particularly in testifying under pressure; preparing concise reports; and testifying in hearings and court proceedings. Skill in establishing and maintaining 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. Word, Excel, and Medicaid Fraud Abuse and Detection System [MFADS] preferred. Ability to prioritize tasks, work under time constraints and under minimal supervision. Ability to develop training materials and use training and/or leadership techniques. Ability to plan, assign and/or supervise the work of others. Ability to travel up to 50% of the time.
The following certifications, designations and/or degrees are desirable and may be well suited to successfully performing this role:
Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Juris Doctorate (JD), Registered Nurse (RN), Licensed Professional Counselor (LPC), Certified Interal Auditor (CIA) or Licensed Clinical Social Worker (LCSW)
Open to internal/external candidates.
1. Graduation from an accredited four-year college or university. May substitute full-time investigation, white-collar crime, auditing, accounting, Medicaid/Medicare program provider compliance monitoring, Managed Care Organization (MCO) experience, legal and/or investigative experience in healthcare insurance or similar experience for required education on a year for year basis.
2. Four years of full-time investigations, auditing, accounting, Medicaid/Medicare Program provider compliance monitoring, white collar crime investigations, legal and/or investigative experience in healthcare insurance or similar experience. May substitute post graduate degree from an accredited four-year college or university in criminal justice or law for required full time investigations experience on a year for year basis.
3. Experience using word processing and electronic spreadsheet applications.
4. Experience with large scale complex investigations and with developing and training others.
5. Ability to travel up to 50% of the time.
1) 5+ years investigative experience directly related to Medicaid, Medicare, Managed Care Organizations (MCO), Healthcare, Fraud/Waste/Abuse.
2) AHFI, CFE, RN or JD designations/degrees.
3) Spanish fluency
4) Knowledge of data analytics, sampling tools, statistical sampling and extrapolations.
Consideration will also be given to known past job performance, if applicable, and prior work history.
Requisition # 473596
The position(s) may be filled at any OIG Medicaid Provider Integrity Office (Austin, Fort Worth Grand Prairie, Houston, Pharr, and San Antonio). Position(s) must be able to work independently as their manager may be at another location.
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 submit to a name-based, or in some instances a fingerprint based, criminal background check through Texas Department of Public Safety (DPS) to determine if an applicant has a conviction for a Class A misdemeanor within the last five years or a felony 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.
The posted salary range reflects the minimum and maximum allowable by state law. 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.
** Current budgetary constraints indicate this position may be filled towards the lower end of the listed pay range **
HHS agencies use E-Verify. You must bring your I-9 documentation with you on your first day of work.
Applicant must be able to meet current HHS and OIG telework standards; and, provide at their own expense, a laptop computer (initially, until state device is issued), high-speed internet access, cellular phone (initially, until state device is issued), and dedicated work space. Employee will be issued a laptop and cellular phone at a later date. Due to the state response to COVID-19 at the time of this posting, this position is currently designated for teleworking.
This position requires the frequent development and completion of complex and lengthy legal documents and reports. This position also requires extensive data analysis and familiarity in working with – and manipulating – large amounts of data within Microsoft Excel. A test related to Excel utilization, data analysis and writing skills may be required following candidate interviews.
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.