Senior Medicaid Investigator

2 weeks ago


Grand Prairie, Texas, United States Texas Department of Aging & Disability Services Full time
Job Overview:

This role is situated within the Provider Field Investigations (PFI) unit of the Medicaid Program Integrity division, reporting directly to a PFI Manager.

The primary responsibility involves conducting administrative inquiries into Medicaid providers concerning allegations of fraud, waste, and/or abuse related to health and human services delivery.

This position enforces relevant state regulations pertaining to these services. Candidates must possess strong interviewing capabilities, comprehensive research and data analysis skills, and the ability to produce intricate investigative reports. The role entails up to 25% travel across the state, including potential overnight stays.

The investigator operates under limited supervision from the PFI Manager, exercising significant initiative and independent judgment.



Note: As of the current job posting, PFI investigators are operating under a mobile work status, which may revert to traditional on-site or telework arrangements based on agency requirements and employee performance.

Key Responsibilities:

Conduct thorough research, review, and investigation of complex complaints and cases related to Medicaid provider fraud, waste, and/or abuse, recommending appropriate actions.

Interpret and apply relevant agency, state, and federal policies, procedures, rules, and regulations.

Execute timely investigative tasks in accordance with PFI policies and procedures, adhering to case-specific deadlines set by management.

Secure approval from the Deputy Inspector General for MPI or their designee to complete a minimum of four comprehensive investigations annually.

Gather, analyze, and interpret business, financial, and medical documentation. (35%)

Summarize and communicate investigative findings through various oral and written formats. Prepare detailed, comprehensive, and grammatically accurate case summaries for each assigned investigation.

Perform timely administrative tasks related to investigations, ensuring compliance with applicable PFI policies and procedures, including investigative timelines.

(10%)
Conduct interviews with recipients, witnesses, providers, complainants, and provider staff regarding investigations. (10%)

Create comprehensive exhibits, including schedules of incorrect claims, to facilitate effective case presentations in administrative hearings and court cases when necessary.

Provide testimony and present evidence in informal reviews and judicial proceedings as required. (10%)
Effectively relay findings to the PFI Manager, Deputy Inspector General for MPI, other staff, and external entities.

Deliver testimony and present evidence in formal hearings and court proceedings; develop and present criminal fraud cases to prosecutors when appropriate.

(15%)

Establish consultative relationships with the Attorney General's Medicaid Fraud Control Unit, the Antitrust and Civil Medicaid Fraud Division, and other state and federal agencies to discuss and coordinate Medicaid provider fraud and abuse investigations; interpret program policies, conduct training workshops, and participate in joint investigations.

(5%)
Develop, recommend, and implement solutions to identified issues.

Review, develop, and propose guidelines, procedures, policies, rules, and regulations aimed at detecting and preventing Medicaid fraud, waste, and program abuse.

Self-initiate cases or projects designed to uncover fraud, waste, and abuse not reported through the referral or MPI Intake process.

(5%)
Assist in the development and delivery of training programs. Mentor and support colleagues and staff from other divisions and agencies as needed. Contribute to the creation of training and operational manuals, educational materials, and relevant information. (5%)
Perform additional duties as assigned to ensure the smooth operation of the division. Keep the manager informed as necessary. (5%).

Required Knowledge, Skills, and Abilities:

Proficient understanding of investigative principles, techniques, and procedures; knowledge of laws governing agency-regulated activities; familiarity with court procedures, practices, and rules of evidence.


Knowledge of Medicaid program policies and procedures, along with an understanding of fraud and abuse regulations.

Ability to interpret and apply policies, procedures, rules, and regulations effectively.

Capable of planning, organizing, and conducting investigations, surveys, inspections, and examinations; conducting interviews and gathering facts; evaluating findings and preparing complex, concise legal reports; and testifying in hearings and court proceedings.


Strong oral and written communication skills.

Ability to establish and maintain effective working relationships with supervisors, colleagues, providers, attorneys, and representatives from other state and federal agencies.

Proficient in using personal computers and related software, including intermediate competency in MS Word and Excel.


Ability to prioritize tasks, work under time constraints, and operate with minimal supervision.

Comfortable working in a virtual environment utilizing tools such as MS Teams, Zoom, WebEx, and similar platforms.


Willingness to travel up to 25% of the time, including statewide and/or overnight travel.

Experience with Medicaid Fraud Abuse and Detection System [MFADS], Business Objects, and PI Case Tracker is preferred.

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