Claims Investigator

Department of Public Safety•El Paso, TX

45d•Hybrid

About The Position

The Office of Inspector General (OIG) Benefits Program Integrity (BPI) Claims Investigator II reports to the BPI unit manager/director. BPI Claims Investigators perform moderately complex investigative work regarding recipients of HHS programmatic services, such as Medicaid; the Children’s Health Insurance Program (CHIP); the Supplemental Nutrition Assistance Program (SNAP); Temporary Assistance for Needy Families (TANF); and the Women, Infants, and Children’s (WIC) program. The BPI Claims Investigator III is responsible for investigating referrals of fraud, waste, and abuse by HHS clients; conducting thorough research and evidence gathering activities; and determining whether the information collected represents a violation of program laws, rules, or regulations according to applicable evidentiary standards. The Claims Investigator II ensures that allegations of client fraud, waste, or abuse are investigated according to law, regulations, agency policies, and professional standards. The position reviews and analyzes records and reports from multiple agency, state, and federal databases; collaborates with both internal and external stakeholders to obtain verification and evidence; understands and applies relevant eligibility requirements; and calculates and establishes overpayment claims. The position obtains business records affidavits, submits subpoenas, and coordinates with law enforcement or other state and federal entities. The Claims Investigator may present cases at both Fair Hearings and Administrative Disqualification Hearings. The position may assist with preparing and presenting training, suggest improvements to BPI’s investigative processes to improve efficiency and promote program integrity, and perform other related duties as assigned. Works under general supervision with limited latitude for the use of initiative and independent judgment as governed by policy and procedures.

Requirements

Graduation from an accredited high school or GED.
Graduation from an accredited four-year college or university with major coursework in business, public administration, criminal justice, or a field related to the assignment OR three years’ experience in applying SNAP, TANF, and Medicaid policies, procedures, and regulations is required.
Experience and education may be substituted on a year-for-year basis.
Current Driver’s License
Knowledge of office management and administrative procedures.
Knowledge of investigative principles, techniques, and standards.
Knowledge of administrative hearing procedures and practices.
Knowledge of state and federal laws, regulations, and policies related to health and human services.
Knowledge of HHS social services programs and eligibility requirements.
Experience in using automated systems for documentation, research, and tracking.
Skill in communicating effectively both orally and in writing.
Skill in conducting legal research and analysis.
Skill in the use of computer/laptop equipment and applicable software applications.
Skill in performing budget calculations and using mathematical formulas.
Skill in handling multiple competing priorities and meeting deadlines.
Ability to establish and maintain effective working relationships with others.
Ability to organize research and gather evidence.
Ability to interpret and apply laws and regulations.
Ability to plan, organize, and conduct investigations.
Ability to conduct investigative interviews.
Ability to comprehend agency policies and guidelines and determine employee or recipient compliance.
Ability to compile, evaluate findings, and present information relevant to investigations.
Ability to use facts to prepare high-quality reports with strong attention to detail.
Ability to testify in hearings or court proceedings.
Ability to develop and present training to others.

Responsibilities

Researches, conducts, collects evidence, reviews records, and examines potential eligibility discrepancies through multiple agency, state, and federal systems to determine program compliance and identify fraud.
Interacts and exchanges information with various internal and external stakeholders; coordinates with law enforcement organizations and other state and federal agencies; and contacts and interviews witnesses and complainants as appropriate to verify recipient case information and evaluate allegations of fraud, waste, and abuse.
Follows HHS and OIG policies and procedures and adheres to applicable investigative standards and evidentiary protocols.
Evaluates, summarizes, and documents investigative findings and prepares detailed, factual investigative case reports.
Calculates overpayments and establishes overpayment claims to recover unauthorized benefit payments.
Prepares correspondence to clients detailing investigative outcomes and provides testimony and presents case file information and evidence at administrative hearings.
Maintains clear investigative documentation and implements well-organized electronic filing and documentation systems.
Employs organizational techniques to manage a high volume of investigations at various stages simultaneously.
Suggests process improvements that increase efficiency and effectiveness of investigative activities and documentation.
Adheres to confidentiality requirements and records retention schedules.
Assists in preparing and delivering training, may assist with policy and procedure or job aid development and review, and may provide input into and assist in testing automated system enhancements or fixes.
Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.