Investigator V

Texas Health & Human Services Commission•San Antonio, TX

11d•$4,801 - $7,762•Onsite

About The Position

The Investigator V conducts and manages all phases of complex, full-scale investigations into alleged Medicaid fraud, waste, and abuse involving providers and non-providers. The position works under minimal supervision with considerable latitude for initiative and independent judgment, and is managed by the Manager of Provider Field Investigations within the Texas Health and Human Services Office of Inspector General. The investigator collaborates with managed care and dental organizations, government agencies, professional and licensing boards, and other entities to coordinate investigations. The role also participates in provider settlement conferences and testifies in court and administrative proceedings. The investigator evaluates claims data, provider records, interviews, and collateral information; performs fieldwork; requests and preserves evidence; and synthesizes findings into reports, memoranda, and exhibits. The position may involve travel up to 25% of the time, including statewide and overnight travel. It is a full-time, regular, nonexempt day-shift position based in San Antonio, with other listed locations in Austin, Edinburg, Grand Prairie, and Houston. The posting states that telework is not eligible, although a general telework disclaimer says eligibility may depend on policy, supervisor discretion, and business needs.

Requirements

Bachelor's degree from a four-year college or university; alternatively, four years of specialized experience may substitute for the education year-for-year, or a combination of education and specialized experience totaling six years may qualify. Experience used toward this requirement must be in addition to the two years required below.
At least two years of specialized experience in investigations, audits, accounting, public policy, healthcare administration, contract monitoring, legal work, Texas Medicaid program experience, or healthcare compliance monitoring in Medicaid or Medicare, MCOs, DMOs, or DSOs.
Advanced knowledge of investigative principles, techniques, procedures, applicable laws, court procedures, practices, and rules of evidence.
Advanced knowledge of Medicaid program policies and procedures and fraud or abuse rules and regulations.
Ability to interpret and apply policies, procedures, rules, and regulations; plan, organize, and conduct investigations; interview people and gather facts; and evaluate findings and prepare complex, concise reports.
Ability to testify in hearings and court proceedings and communicate effectively verbally and in writing.
Ability to maintain discretion and confidentiality, exercise sound judgment, and establish effective professional relationships.
Ability to use computers and related software, including advanced Microsoft Excel functions and formulas for queries, reports, pivot tables, and graphs, and Microsoft Word for correspondence and investigative documentation.
Ability to prioritize work, meet time constraints, and work in a virtual environment using tools such as MS Teams, Zoom, or WebEx.
Ability to travel up to 25%, including statewide and/or overnight travel.
Selected applicants must complete a national fingerprint-based criminal background check through the Texas Department of Public Safety and FBI.

Nice To Haves

Preferred certifications or licenses include Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Inspector General Investigator (CIGI), Registered Nurse (RN), Licensed Professional Counselor (LPC), Certified Internal Auditor (CIA), Registered Dental Hygienist (RDH), Certified Pharmacy Technician (CPhT), and Licensed Clinical Social Worker (LCSW).

Responsibilities

Conduct and manage complex investigations of alleged Medicaid provider and non-provider fraud, waste, and abuse, including investigative phases, workflows, tasks, and deliverables.
Research and analyze background information, claims data, provider records, interviews, and collateral information to identify leads, corroborate evidence, and maintain complete investigative records.
Perform fieldwork, including provider, staff, and client interviews, documentation, witness statements, and surveillance.
Interpret and apply laws, rules, statutes, policies, and procedures relevant to investigations.
Maintain the case management system and electronic case files.
Request and collect business, financial, and medical records; draft administrative subpoenas and coordinate with OIG Chief Counsel on legal defensibility.
Review evidence, follow up on record requests, address extension requests with leadership, and ensure responsive documentation is received by deadlines.
Preserve evidence and evidentiary integrity according to chain-of-custody standards.
Prepare reports, memoranda, and exhibits, including schedules of incorrect claims, and present investigative findings in hearings and proceedings.
Testify and present evidence during informal reviews, administrative court proceedings, and court proceedings.
Coordinate with managed care and dental organizations, government agencies, professional and licensing boards, and other partners; maintain relationships and participate in meetings.
Recommend and collaborate on process and policy improvements, job aids, and training; share information in accordance with confidentiality and statutory requirements.
Identify fraud patterns and vulnerabilities, evaluate investigative challenges, and develop investigative strategies for leadership approval.
Attend work on a regular and predictable schedule, keep the manager informed as required, and perform other duties as assigned.