Investigator V

TX-HHSC-DSHS-DFPS•Edinburg, TX

7d•Onsite

About The Position

This position is housed within the Provider Field Investigations (PFI), Medicaid Program Integrity unit of the Investigations & Utilization Reviews (I&UR) division of the Office of Inspector General (OIG) and reports directly to a PFI Manager. Performs highly complex administrative investigations of Medicaid providers and non-providers involving allegations of fraud, waste and/or abuse in the provision and delivery of all health and human services in the state. This role requires interviewing skills, extensive research & data analysis, and the development of complex investigative reports. Work involves up to 25% statewide travel, which includes some overnight travel. The Investigator works under limited supervision of the PFI Manager with considerable latitude for the use of initiative and independent judgment.

Requirements

Advanced knowledge of investigative principles, techniques, and procedures; of the laws governing the activities regulated by the agency; and of court procedures, practices, and rules of evidence.
Advanced 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.
Ability to plan, organize, and conduct investigations; to conduct interviews and gather facts; to evaluate findings and prepare complex, concise reports; and to testify in hearings and court proceedings.
Ability to communicate effectively both orally and in writing.
Ability to establish and maintain effective, professional 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, to include the ability to analyze complex queries using advanced functions and formulas in Microsoft Excel to develop reports, pivot tables, and graphs; and ability to prepare correspondence using Microsoft Word to respond to requests and document investigative findings.
Ability to prioritize tasks; work under time constraints and under limited supervision.
Ability to work in a virtual environment with tools such as MS Teams, Zoom, WebEx and/or other similar platforms.
Ability to travel up to 25% of the time, to include statewide and/or overnight travel.
HHSC internal applicants only.
Requirement #1: Graduation from a four-year college or university, which culminated in a bachelor's degree; OR Requirement #1: Four years of specialized experience, as defined below, may be substituted for the required education on a year-for-year basis. (NOTE: Any year of specialized experience counted towards Requirement #1 must be in addition to the two years of specialized experience qualified for Requirement #2, below.) OR Requirement #1: Any combination of years of education and specialized experience, as defined below, that total six. (NOTE: Any year of specialized experience counted towards Requirement #1 must be in addition to the two years of specialized experience qualified for Requirement #2, below.) AND Requirement #2: Two years of specialized experience in any of the following areas: investigations, audits, accounting, public policy, healthcare administration, contract monitoring, legal work, Texas Medicaid program experience and/or healthcare compliance monitoring in Medicaid or Medicare, Managed Care Organizations (MCO), Dental Maintenance Organizations (DMO), and/or Dental Service Organizations (DSO).

Nice To Haves

Graduate Degree in Public Administration, Public Health or Public Policy (or similar)
Bilingual in English/Spanish
Certified Fraud Examiner (CFE)
Accredited Healthcare Fraud Investigator (AHFI)
Certified Inspector General Investigator (CIGI)
Juris Doctorate (JD)
Registered Nurse (RN)
Licensed Professional Counselor (LPC)
Certified Internal Auditor (CIA)
Registered Dental Hygienist (RDH)
Certified Pharmacy Technician (CPhT)
Licensed Clinical Social Worker (LCSW)

Responsibilities

Conducts full-scale investigations of alleged Medicaid provider fraud, waste, and/or abuse of each case assigned in accordance with all applicable statutes, administrative rules, and OIG policies and procedures.
Performs necessary investigative fieldwork tailored to the needs of each case, including, but not limited to: provider, staff, and client interviews (including required interview documentation); witness statements; and/or surveillance.
Collects business, financial, and medical records in accordance with OIG policies; and ensures the proper use of agency records-collection forms.
Preserves evidentiary integrity by following chain-of-custody standards for all collected documents, digital or electronic media, and physical evidence.
Conducts background research, data review, and case-specific analysis to identify investigative leads, corroborate evidence, and ensure a complete investigative record.
Researches, interprets and applies applicable laws, rules, statutes, policies and procedures according to the facts of the case.
Manages all phases of assigned investigations in accordance with OIG policies and procedures, job aids, investigative timelines, and applicable statutes and rules.
Ensures timely completion of investigative milestones, tasks, and deliverables, as assigned.
Prioritizes workload and adjusts strategies to maintain consistent progress toward established deadlines.
Conducts thorough, objective investigations that rely solely on verifiable evidence.
Applies advanced investigative techniques to evaluate claims data, provider records, interviews, and collateral information.
Reaches conclusions that are fact-driven, defensible, and aligned with program integrity standards.
Maintains professionalism and a composed demeanor in all communications and interactions with providers, internal OIG staff, external agencies, and all other stakeholders.
Demonstrates respectful, clear, and appropriate communication in person, virtually, and via email.
Fosters trust, cooperation, and mutual respect throughout the investigative process.
Exhibits the core values of the OIG: Accountability, Integrity, Collaboration and Excellence.
Exhibits a “team player” attitude and actively shares institutional knowledge and lessons learned amongst other OIG units.
Summarizes investigative findings into concise, accurate, grammatically correct and well-structured investigative reports and memoranda which are tailored to the intended audience.
Presents investigative outcomes verbally, virtually or in writing to internal leadership, external agency partners, legal staff, and other stakeholders as required.
Clearly explains investigative rationale, evidentiary foundations, and recommended actions.
Develops comprehensive exhibits, including but not limited to, a schedule of incorrect claims, to ensure effective case presentations in administrative hearing and court cases, when required.
Testifies and presents evidence in informal reviews and judicial proceedings, as needed.
Conducts consultative meetings and maintains cooperative working relationships with external stakeholders such as the Managed Care Organizations, Dental Maintenance Organizations, OAG’s Medicaid Fraud Control Unit and the OAG’s Healthcare Program Enforcement Division, federal partners, licensure boards, other OIG divisions, and HHSC program areas.
Coordinates investigative activities, shares relevant information, and supports joint initiatives in accordance with confidentiality and statutory requirements.
Performs other duties as assigned or required to maintain division operation. Keeps manager informed as required or as necessary.

Benefits

comprehensive benefits package includes 100% paid employee health insurance for full-time eligible employees, a defined benefit pension plan, generous time off benefits, numerous opportunities for career advancement and more

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