Claims Investigator
About The Position
The Office of Inspector General (OIG) Benefits Program Integrity (BPI) Claims Investigator II conducts moderately complex investigations involving recipients of HHS programs, including Medicaid, CHIP, SNAP, TANF, and WIC. The investigator reviews allegations of fraud, waste, or abuse; researches records and gathers evidence; and determines whether collected information indicates a violation of applicable program laws, rules, or regulations under relevant evidentiary standards. The position reviews records and reports from agency, state, and federal databases, collaborates with internal and external stakeholders to obtain verification and 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 materials, job aids, and automated system enhancements, and may suggest improvements to investigative processes. Work is performed under general supervision with limited latitude for initiative and independent judgment within policy and procedures.
Requirements
- Graduation from an accredited high school or GED.
- A four-year college or university degree 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 procedures, and state and federal laws, regulations, 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.
- Ability to communicate effectively orally and in writing; conduct legal research and analysis; use computer and laptop equipment and applicable software; perform budget calculations; and manage competing priorities and deadlines.
- Ability to establish effective working relationships; organize research and gather evidence; interpret and apply laws and regulations; plan and conduct investigations and interviews; and assess compliance with agency policies and guidelines.
- Ability to compile and evaluate findings, present investigation-related information, prepare detailed reports, testify in hearings or court proceedings, and develop and deliver training.
- Ability to travel up to 20%.
Responsibilities
- Research potential eligibility discrepancies and investigate allegations of fraud, waste, or abuse using agency, state, and federal systems.
- Collect and review evidence and records to determine program compliance.
- Exchange information with internal and external stakeholders, coordinate with law enforcement and other state and federal agencies, and interview witnesses and complainants as appropriate.
- Follow HHS and OIG policies, procedures, investigative standards, and evidentiary protocols.
- Evaluate and document findings and prepare detailed, factual investigative case reports.
- Calculate overpayments and establish claims to recover unauthorized benefit payments.
- Prepare correspondence to clients explaining investigative outcomes.
- Present case file 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.
- Suggest improvements to the efficiency and effectiveness of investigative activities and documentation.
- Adhere to confidentiality requirements and records retention schedules.
- Assist with preparing and delivering training and with developing or reviewing policies, procedures, and job aids.
- Provide input into and assist with testing automated system enhancements or fixes.
- Attend work on a regular and predictable schedule and perform other duties as assigned.
Benefits
- 100% paid employee health insurance for full-time eligible employees
- Defined benefit pension plan
- Generous time off benefits
- Opportunities for career advancement
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
