Senior Research Specialist

Job Description:
The Fraud Analytics (FA) unit within the Data Reviews Division of the Office of Inspector General (OIG) is seeking a Senior Research Specialist (Research Specialist IV) to expand the team’s research capacity. The Fraud Analytics unit is responsible for performing innovative data analytics that seek to maximize the identification of fraud, waste, and abuse (FWA) in state health and human services programs such as Medicaid (including Managed Care), CHIP, SNAP and TANF by providing data-driven insights that inform investigations, reviews, audits, and inspections. The Research Specialist will perform research and analysis that support this effort by enhancing Fraud Analytics’ ability to leverage complex healthcare data and advanced analytics to effectively identify FWA.

The FA Research Specialist oversees complex project development, conducts thorough policy and data research, and produces clear deliverables and reports. This position reports to the Director of Fraud Analytics and works under limited supervision, with significant latitude for the use of initiative and independent judgment. This position works closely with Fraud Analytics team members, internal OIG units, and external entities, and may provide guidance to others.

The FA Research Specialist is responsible for developing and reviewing policies and procedures used in conducting and administering research activities, establishing quality assurance procedures, conducting quality assurance reviews on research projects, and consulting and providing technical advice on research methods and techniques.

This position serves as a subject matter expert in health and human services program data and healthcare FWA schemes and scenarios. The position prepares written project plans, including objectives, scope, and methodology; prepares presentations and research findings; and assists with validation of research outcomes through data analysis and evaluation. Outcomes that support and/or directly inform work of FA data analysts and data scientists will advance team objectives by facilitating new FWA lead generation resulting from the augmentation of existing detection strategies and the development and deployment of novel strategies.

*** This position can telework % from any OIG location within Texas consistent with HHS telework policies. *** Essential Job Functions:
Attends work on a regular and predictable schedule in accordance with agency leave policy and performs duties as assigned:

1. Conducts complex and thorough policy research, data analysis, and evidence gathering activities to determine potential violations of program laws, rules, regulations, and acceptable industry practices. Assists with gathering and interpreting relevant program laws, regulations, and requirements; agency policies, procedures, and systems; and medical coding practices. Identifies inconsistencies and assists with obtaining expert and legal clarification. Suggests opportunities to enhance or clarify policy or procedures to improve outcomes and prevent fraud, waste, and abuse. (30%)

2. Reviews data and conducts quality assurance activities to validate observable trends, outliers, or other patterns of behavior that may represent violations of Medicaid or other state health and human services program requirements. Analyzes complex medical and claims data to compare patterns of behavior with policy research. Proactively reviews available research, collaborates with peers, and monitors internal and external sources to identify and track current trends. (20%)

3. Effectively communicates findings and related recommendations to the FA team, other OIG units, and external entities, including: data analysts and data scientists, OIG program area customers, the OIG executive team, and contractors/vendors. Writes methodology documents and detailed reports; prepares and delivers presentations and data visualizations. (15%)

4. Serves as a subject matter expert in health and human services program policies and data. Closely collaborates with the OIG Policy and Strategic Initiatives team to obtain policy clarifications and make policy recommendations. Serves as a liaison to other state agencies, licensures boards, and federal agencies regarding fraud, waste and abuse in state health and human services programs. (10%)

5. Assists with the development of new FA projects and initiatives, including the development of project plans; the creation of templates and tools to support evidentiary requirements; and the presentation of reports and findings to both internal and external stakeholders. Conducts related training, as needed. Ensures that work performed by the FA team complies with applicable rules, laws and professional standards. Completes project deliverables in accordance with applicable timelines, metrics, quality standards, and OIG leadership expectations. (5%)

6. Develops solutions to increase the efficiency and effectiveness of division activities, promote consistency, and support program integrity. Coordinates activities to foster collaboration and to improve internal and external communication, outcomes, and program integrity. (5%)

7. Responds to inquiries and ad hoc requests expediently, professionally and in accordance with defined timeframes. Effectively reports deliverables, recommendations, challenges and action items, as appropriate. (5%)

8. Compiles and develops executive briefing documents, issue papers, reports, and memoranda for executive decision making and delivers executive level briefings as needed and appropriate, in coordination with the Director of Fraud Analytics. (5%)

9. Performs other duties necessary to achieve the mission of the Office of Inspector General. Statewide travel of about 5% may be required. (5%) Knowledge Skills Abilities:
1.Knowledge of principles and practices of public administration and management.
2.Knowledge of state and federal laws, regulations, and policies related to health and human services.
3.Knowledge of the OIG operating procedures as well as the OIG’s enabling legislation.
4.Knowledge of Medicaid policy and billing requirements and allowable coding practices.
5.Knowledge of research principles, techniques, procedures and best practices.
6.Knowledge of analytical and statistical tools, methods, and techniques; of data models and querying relational databases; of data wrangling, mining and visualization techniques; and of record keeping, including security procedures for handling, protecting, and distributing confidential data.
7.Skill in critical thinking, analyzing problems, and devising effective solutions.
8.Skill in collecting, reviewing, cleaning and analyzing large, complex datasets.
9.Skill in verbal and written communication essential to effectively interacting with OIG customers, leadership, and team members.
10.Skill in conducting quality assurance activities and identifying trends that indicate a need for policy or process improvements or additional training. Skill in using automated systems for documentation, research, tracking and version control.
11.Ability in applying Medicaid requirements to development of rules-based and data-driven strategies for discovering trends and patterns and deriving insights that facilitate FWA detection and provider investigations.
12.Ability to evaluate information, draw logical conclusions, and effectively communicate complex findings and methodologies to non-technical audiences in concise reports and presentations.
13.Ability to use facts to prepare high-quality investigative reports and factual, convincing arguments to clearly demonstrate fraud, waste, and abuse.
14.Ability to apply agency policies and guidelines and determine compliance.
15.Ability to work independently, exercise independent judgment, prioritize tasks, and manage multiple projects/assignments/responsibilities in a fast-paced environment under time constraints.
16.Ability to establish and maintain effective working relationships with others.
17.Ability to work in teams that may cross departments and/or agencies.
18.Ability to develop training materials and provide guidance and training to others.

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