Occ. Code 6636150

 

                                                                                                                                                        

medicaid INVESTIGATOR 1, GRADE 17

6636150

medicaid INVESTIGATOR 2, GRADE 21

6636250

medicaid INVESTIGATOR 3, GRADE 24

6636350

medicaid INVESTIGATOR 4, GRADE 27

6636450

medicaid INVESTIGATOR 5, M-4

6636550

 

New York State Department of Civil Service

 

Classification Standard

 

BRIEF DESCRIPTION OF CLASS SERIES

 

Medicaid Investigators use various methods to identify cases of Medicaid fraud and abuse and to analyze, review, and refer such cases for administrative and legal action.  The levels of Medicaid Investigator are distinguished by the scope and methods of investigation, supervisory responsibility, and authority for pursuing and referring cases for legal action.  They are classified predominantly in the Office of the Medicaid Inspector General (OMIG).  All positions of Medicaid Investigator are in the non-competitive jurisdictional class.

 

DISTINGUISHING CHARACTERISTICS

 

Incumbents conduct standard and undercover investigations and obtain, analyze, organize, and summarize statements, documents, records, exhibits, recordings, and photographs to identify instances of fraud and abuse in the New York State Medicaid program.  Examples of fraud and abuse include, but are not limited to, schemes designed to illegally obtain and distribute prescription drugs that are reimbursed by Medicaid and provision of excessive or suspect care to Medicaid patients by medical providers.

 

medicaid INVESTIGATOR 1:  entry level; under supervision, conducts routine and standard investigations where the elements of the case are straightforward and/or the law or facts of the case are not in dispute.  Incumbents analyze and review cases of potential Medicaid fraud, waste, and/or abuse and/or serve on teams investigating Medicaid providers. 

 

medicaid INVESTIGATOR 2:  full-performance level; may supervise, lead a team of investigators, work independently, or participate on joint investigative task forces involving other agencies or federal authorities.  Incumbents conduct investigations that are more difficult or where there exist questions of Medicaid Law or the facts of the case are in dispute.  Alternatively, Medicaid Investigators 2 lead investigations where the facilities and/or programs being reviewed are large and require investigations of several operational levels and/or fiscal program review. 

 

medicaid INVESTIGATOR 3:  supervisory level; supervises a team or teams of professional investigative staff usually headed by a Medicaid Investigator 2; coordinates investigator workload for assigned unit, evaluates investigative data, and compiles and reviews data for investigative report recommendations. 

 

medicaid INVESTIGATOR 4:  manager level; provides administrative oversight of a unit or group consisting of multiple teams of investigators.  The Medicaid Investigator 4 oversees the investigation process involving cases that are likely to lead to criminal prosecution, civil litigation, and/or administrative action, provides overall policy and program guidance to investigative program staff, and participates in planning and coordinating the overall fraud and abuse detection program.

 

medicaid INVESTIGATOR 5:  director level; oversees and coordinates the overall Medicaid anti-fraud investigations function.   Recommends policy changes to ensure the Medicaid Program is compliant with existing State and federal law and is operating efficiently.  Implements policy change determinations of the Medicaid Inspector General and executive staff.

 

ILLUSTRATIVE DUTIES

 

medicaid INVESTIGATOR 1

 

Analyze and review data from various sources to identify potential fraud, waste, and/or abuse.

 

·         Compile findings and analyses into narrative and statistical reports.  Maintain status of current assignments using an electronic case tracking system.  Draft comprehensive written investigation reports, including reports recommending investigation disposition.

 

 

 

 

·         Perform investigations and reviews in compliance with New York State Penal Code and federal law.  Work with Medicaid Investigators, Management Specialists, and others with appropriate jurisdiction, to obtain necessary legal instruments to perform required investigations and consult with legal staff to ensure that investigative procedures and techniques comply with individual rights and due process. 

 

 

 

As directed, testify in proceedings relative to assigned investigations.

 

medicaid INVESTIGATOR 2

 

Perform the duties and functions of Medicaid Investigators 1 for investigations that are more difficult or where Medicaid Law requires interpretation, or where the facts of the investigation under review are not firmly established. 

 

Perform undercover activity that may be less routine or more difficult.   

 

May supervise a small team of subordinate investigative staff or serve as lead investigator for assigned investigations.  Provide training and/or mentoring to Medicaid Investigators 1 or other staff as directed; and identify training needs.

 

·         Determine project assignments; set priorities and deadlines.

 

·         Research NYS Penal Code and federal law and assist staff in its correct application. 

 

·         Provide interim case reports to supervisor to communicate progress and issues and to determine feasibility of continuing or concluding particular cases.

 

As directed, testify in proceedings relative to assigned investigations.

 

medicaid INVESTIGATOR 3

 

Perform the duties and functions of Medicaid Investigators 1 & 2; supervise and coordinate workload for assigned staff.

 

·         Assign cases and distribute workload to investigative teams.  Determine and oversee staff assignments.  Meet with staff to discuss strategies, establish priorities, deadlines, and anticipated deliverables.

 

·         Approve leave and track time and attendance.

 

·         Review, monitor, and evaluate staff performance.  Prepare and/or review probation and performance evaluations.

·         Identify training needs and participate in and/or arrange for training of staff on latest techniques and best practices in investigation and fraud and abuse detection. 

 

Actively participate in investigations.

 

·         Analyze data or reports of data from various sources, or review referrals to establish priorities.  Initiate proactive investigations.

 

·         Review and submit complete written investigative reports to legal staff for their submission to the appropriate prosecutorial or administrative authority.

 

·         Coordinate large-scale investigations, especially those involving outside agencies.  Develop and maintain contacts in those agencies. 

 

·         Supervise undercover shops and credential verification reviews by investigators.

 

·         Perform and/or supervise the collection and analysis of documentary evidence including interviews and witness statements. 

 

·         Research the NYS Penal Code and federal law as it applies to fraudulent activities and the Medicaid Program; provide guidance and coaching to subordinate staff regarding its application and/or legal procedures for obtaining information.

 

Ensure that standards for maintaining the security of confidential files and information are followed.

 

Provide recommendations for the development of investigative procedures, policies, and tactics to prevent, detect, and investigate fraudulent claims and abusive practices.  Develop creative, defensible investigative strategies and standards.

 

·         In consultation with legal staff, update the investigation manual.

 

·         Implement program integrity measures identified during investigative activities in consultation with appropriate staff. 

 

Testify in hearings or in court where required, and/or direct and oversee attendance of subordinate personnel at hearings and in court.

 

medicaid INVESTIGATOR 4

 

May perform the duties and functions of Medicaid Investigators 3, supervise multiple teams headed by Medicaid Investigators 3 or equivalent, and provide overall program guidance to investigative program staff.

 

·         Oversee staffing, recruitment, staff development/training, and succession management planning for assigned units.  Review and rate the work of subordinate investigators and staff.  Prepare and/or review probation and performance evaluations.

 

·         Supervise the assignment of cases, distribution of workloads, establishment and progress of project deadlines, and all related activities for assigned Medicaid investigative program area. 

 

·         Participate in the most difficult cases where added expertise is required.

 

·         Participate in planning and coordinating the overall fraud and abuse detection program.

 

·         Develop new methods and procedures to prevent, detect, and investigate fraudulent claims or practices. 

 

·         Meet with supervising Investigators to discuss investigative targets and goals, develop strategies, and set programmatic priorities for assigned Medicaid investigative program area.

 

·         Ensure that legal requirements are maintained and followed by subordinate staff.

 

·         Establish standards for maintaining the security of confidential files and reports, and supervise the administration of confidential information.

 

·         Testify in hearings or in court where required, and/or direct and oversee attendance of subordinate personnel at hearings and in court.

 

medicaid INVESTIGATOR 5

 

This is a one position class that reports directly to the Deputy Medicaid Inspector General (MIG) for Investigations.  Assists the Deputy MIG in managing statewide operations in Medicaid fraud and abuse detection programs and directs, manages, and oversees ongoing activities and administrative functions for the Division of Medicaid Investigations (DMI).

 

·         In conjunction with the Deputy MIG and DMI supervisors and managers, develops program and operational goals, objectives, and work plans for the Division of Medicaid Investigations (DMI).  Directs the development of investigative plans and monitors the implementation of program objectives and accomplishments.

 

·         Develops investigative procedures, advanced tactics, and strategies. 

 

·         Coordinates activity with outside investigative agencies such as the State Medicaid fraud control units (MFCUs), federal Department of Health and Human Services (HHS), Office of the Inspector General (OIG), local district attorney offices, US Attorney, and Federal Bureau of Investigation (FBI). 

 

·         Assists the Deputy MIG as necessary in representing the MIG in meetings and/or negotiations and in the absence of, or upon delegation by the Deputy MIG, assumes responsibility for the management of any or all division programs and activities.

 

·         Communicates directives on behalf of the Deputy MIG.

 

·         Meets with senior management within OMIG to recommend changes in agency policy on fraud investigations, providers, and techniques.

 

MINIMUM QUALIFICATIONS

 

 

            Medicaid Investigator 1

Six years of full-time professional investigative experience* in a position primarily involving field investigation and the preparation of detailed narrative reports.

 

            Medicaid Investigator 2

 

Eight years of full-time professional investigative experience* in a position primarily involving field investigation and the preparation of detailed narrative reports.

 

            Medicaid Investigator 3

 

Ten years of full-time professional investigative experience* in a position primarily involving field investigation and the preparation of detailed narrative reports; two years of which must have been in a supervisory**, team leader, or lead worker position.

 

            Medicaid Investigator 4

           

Twelve years of full-time professional investigative experience* in a position primarily involving field investigation and the preparation of detailed narrative reports; a minimum of 4 years of which included experience in direct supervision.**

 

Medicaid Investigator 5 

 

Fourteen years of full-time professional investigative experience* in a position primarily involving field investigation and the preparation of detailed narrative reports; five years of which must have included experience in direct supervision and/or supervision** of teams of investigators and providing overall program guidance to investigative program staff.

 

For each title, college education may be substituted for up to three years of experience at the rate of 30 credit hours equaling one year.  A bachelors degree in Criminal Justice, Police Science, Human Services, a health care-related field, Accounting, or Auditing may be substituted for four years of general experience.  An advanced degree in Criminal Justice or Law may be substituted for an additional year of general experience.

 

* Qualifying investigative experience may include conducting interviews of witnesses and others; conducting interrogations; taking written statements and affidavits; collecting and analyzing physical and documentary evidence; preparing detailed written reports of investigative findings; conducting investigations preliminary to administrative actions, civil litigation, or criminal prosecution; and testifying in court or at formal hearings.

 

**Qualifying supervisory experience includes identifying potential targets; establishing priorities and deadlines; initiating investigations; developing investigation strategies and techniques; providing input into the development of agency protocols on fraud investigations, providers, and techniques; supervising the assignment of cases, distribution of workloads, and establishment and progress of project deadlines; approving leave and monitoring time and attendance; completing performance evaluations; identifying staff development needs; and arranging for appropriate training.

 

Examples of non-qualifying experience: experience in routine police patrol work, tax collection, collection of delinquent accounts, credit checking, hotel or store detective, parole officer, correction officer, guard, inspector, or a security-related position is not considered qualifying experience.

 

Fingerprinting and a thorough background check are part of the selection process for all classes in this series.

 

 

Date:  6/13

 

 

NOTE:  Classification Standards illustrate the nature, extent, and scope of duties and responsibilities of the classes they describe.  Standards cannot and do not include all of the work that might be appropriately performed by a class.  The minimum qualifications above are those that were required for appointment at the time the Classification Standard was written.  Please contact the Division of Staffing Services for current information on minimum qualification requirements for appointment or examination.