Claims Investigator

Texas Health & Human Services Commission•El Paso, TX

4d•$3,410 - $4,252

About The Position

The Office of Inspector General (OIG) Benefits Program Integrity (BPI) Claims Investigator II performs moderately complex investigative work involving recipients of HHS programs, including Medicaid, CHIP, SNAP, TANF, and WIC. The investigator reviews referrals of suspected client fraud, waste, or abuse; researches and gathers evidence; and determines whether the evidence indicates a violation of applicable laws, rules, or regulations. The role reviews records and reports from agency, state, and federal databases; works with internal and external stakeholders to verify information and obtain evidence; applies program eligibility requirements; and calculates and establishes overpayment claims. Duties also include obtaining business records affidavits, submitting subpoenas, coordinating with law enforcement and other government entities, and presenting cases at Fair Hearings and Administrative Disqualification Hearings. The investigator may assist with training, policy and procedure or job-aid development, and automated system testing, and may recommend improvements to investigative processes. The position works under general supervision with limited latitude for initiative and independent judgment, guided by policies and procedures. It requires up to 20% travel and regular, predictable attendance.

Requirements

High school graduation or GED.
A four-year degree from an accredited college or university with major coursework in business, public administration, criminal justice, or a related field, or three years of experience applying SNAP, TANF, and Medicaid policies, procedures, and regulations; education and experience may be substituted year for year.
Current driver's license.
Knowledge of office management and administrative procedures, investigative principles and standards, administrative hearing practices, and laws and policies related to health and human services.
Knowledge of HHS social services programs and eligibility requirements.
Experience using automated systems for documentation, research, and tracking.
Oral and written communication, legal research and analysis, computer and software, mathematical calculation, prioritization, and deadline-management skills.
Ability to establish working relationships; organize research and gather evidence; interpret and apply laws and regulations; plan and conduct investigations and interviews; assess compliance; evaluate findings; prepare detailed reports; testify in hearings or court proceedings; and develop and present training.
Ability to travel up to 20%.

Responsibilities

Research referrals and investigate possible client fraud, waste, and abuse using agency, state, and federal systems and records.
Collect and review evidence, assess eligibility discrepancies, and determine program compliance using applicable investigative and evidentiary standards.
Interview or contact witnesses and complainants as appropriate to verify case information and evaluate allegations.
Coordinate with internal and external stakeholders, law enforcement organizations, and state and federal agencies.
Evaluate, summarize, and document findings in detailed, factual investigative case reports.
Calculate overpayments and establish claims to recover unauthorized benefit payments.
Prepare client correspondence describing investigative outcomes.
Present case information and evidence, and provide testimony, at administrative hearings.
Maintain clear investigative documentation and organized electronic filing systems while managing multiple investigations at different stages.
Protect confidential information and follow records-retention schedules and applicable agency policies and procedures.
Suggest improvements to investigative processes and documentation practices.
Assist with preparing and delivering training; may help develop or review policies, procedures, and job aids, and provide input into or assist with testing automated system enhancements or fixes.
Attend work on a regular and predictable schedule and perform other duties as assigned.