MCU Investigator V

Texas Health & Human Services Commission•Austin, TX

2d•$4,801 - $7,762•Hybrid

About The Position

This Investigator VI is selected and managed by the Major Case Unit (MCU) manager within the Investigations & Utilization Reviews (I&UR) division of the Office of Inspector General (OIG). Performs highly advanced (senior level) investigative work 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, advanced investigative skills, and the development of complex investigative reports. Work involves up to 25% statewide travel, which may include some overnight travel. The investigator works minimal supervision with extensive latitude for the use of initiative and independent judgment.

Requirements

Knowledge and experience in complex investigative principles, techniques, and procedures.
Knowledge of the laws governing the activities regulated by the agency, court procedures, rules of evidence, criminal prosecutions, civil actions, and contract law.
Knowledge of Medicaid program policies and procedures.
Knowledge of fraud and abuse rules and regulations.
Knowledge of business structures (corporate, partnership, LLC)
Experience in opens source investigative techniques (OSINT)
Ability to understand, interpret, and appropriately apply policies, procedures, rules, and regulations.
Ability and skill to plan, organize, and conduct complex investigations; use data analytics to analyze investigative date, use AI for complex searches, conduct interviews and gather facts; evaluate findings, prepare complex, concise reports; 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, team members, MCOs, providers, attorneys and individuals from other state and federal agencies and boards.
Ability to use personal computers and related software to analyze complex queries using advanced functions and formulas in Microsoft Excel, Power BI, and other applications as required.
Ability to prioritize tasks; work under time constraints and under minimal supervision.
Ability to travel up to 25% of the time, to include statewide and/or overnight travel.
Ability to multi-task and track multiple activities with competing priorities.
Ability to work independently.
Ability to exercise professional judgment and reach sound decisions.
Ability to integrate complex regulatory concepts, procedures, and processes.
Skilled in creating comprehensive reports, analyzing data insights, and developing clear, impactful visualizations and preparing correspondence using Microsoft Word to respond to requests and document investigative findings.
Graduation from an accredited four-year college or university.
Experience in writing detailed reports.
Experience operating personal computers and software.
Experience conducting complex investigations preferred.

Nice To Haves

Certified Fraud Examiner (CFE) certification preferred.
Experience conducting complex investigations preferred.

Responsibilities

Research, review, and objectively investigate complex cases alleging fraud, waste, and/or abuse in the provision and delivery of all health and human services in the state. Interprets and applies applicable agency, state and federal policies, procedures, rules, and regulations. Performs timely investigative analysis in conformity with applicable policies and procedures. (35%)
Evaluates, summarizes, and communicates investigative findings through various oral and written communications. Prepare detailed, comprehensive internal reports. Develop comprehensive fact-based exhibits to ensure effective case presentations in administrative hearings and court cases, when required. Testifies and presents evidence in informal reviews and judicial proceedings (before administrative, civil, and criminal courts) as needed. (25%)
Research potential interviewees related to the investigation. Conducts professional interviews with recipients, witnesses, providers, complainants, and provider’s staff regarding investigations. (15%)
Provides law enforcement assistance in criminal fraud cases to criminal investigators and prosecutors when necessary. Establishes liaisons with the Office of Attorney General’s Medicaid Fraud Control Unit, the Healthcare Program Enforcement Division, Managed Care Organizations (MCOs) other state and federal agencies, licensure boards, and other external entities to discuss and/or coordinate complex cases alleging fraud, waste, and/or abuse in the provision and delivery of all health and human services in the state. (10%)
Develops, recommends, and implements solutions to problems. Reviews, develops, and recommends guidelines, procedures, policies, rules, and regulations to detect and prevent fraud, waste, and program abuse in the provision and delivery of all health and human services in the state. Self-initiates cases or projects designed to generate cases to prevent, detect and investigate fraud, waste and abuse not reported through the OIG referral process. (10%)
Performs other duties as assigned or required to maintain division operation. Keeps manager informed as required or as necessary. (5%).