Both position levels require travel throughout the state of Minnesota, with some overnights. As such, a valid driver’s license is required at time of appointment, along with the entirety of duration in this position.
The Healthcare Fraud Investigator or Senior Healthcare Fraud Investigator is part of the Surveillance and Integrity Review Section (SIRS) in the Office of the Inspector General. As a requirement of participation in Medicaid, the federal government requires the state Medicaid agency to have SIRS to conduct post payment review of provider claims to identify fraud, waste and abuse.
With over 90 provider types and 182 million claims submitted per year, SIRS investigators must carefully analyze documents to determine if all DHS requirements for payment are met. If not, actions may include recovery of overpaid amount, fines, education of provider, suspension/termination of provider’s enrollment or referral for criminal investigation.
Investigators must write clear and accurate reports of all
activities and be prepared to testify at administrative hearings or
in criminal proceedings. In addition, SIRS investigators refer over
100 cases annually to law enforcement agencies for consideration of
Human Services Program Representative 1 Minimum Qualifications
- Bachelor's degree or higher in criminal justice, accounting, or a health care auditing/investigations related field may substitute for one year of related professional experience.
- Experience must demonstrate the following:
- Investigative techniques and their application to various situations and populations
- Understanding, interpretation and application of Minnesota statutes and rules
- Knowledge of the current methods of investigating and health care billing
- Knowledge of the role and function of other investigative agencies and law enforcement
- Work with state and federal laws related to Medical Assistance fraud or misuse, fraud investigations, due process, subpoenas, and data privacy or Health Insurance Special Investigations
- Strong investigative techniques and problem resolution skills in order to manage the investigation and resolution of complex SIRS cases within limitations set by regulations, law and policy
- Analyzing fiscal and statistical data and identify discrepancies
- Producing clear and concise investigative summary reports and/or correspondences
- Preparing legal documents such as case summaries and subpoenas
- Preference will be given to candidates who are registered nurses, mental health professionals, allied health professionals (for example physical therapy, occupational therapy, respiratory therapy, speech therapy) and auditors who possess a Bachelor's degree in accounting, finance, criminal justice or related field
- Experience performing investigations of claims payments submitted to private or public health insurance companies or to federal health care programs.
- Knowledge of related state and federal laws and applicable rules and procedures which govern health care programs.
- Knowledge of audit and accounting procedures.
- Experience in conducting complex investigations based upon information analysis.
REFERENCE/BACKGROUND CHECKS - The Department of Human Services will conduct reference checks to verify job-related credentials and criminal background check prior to appointment.
Why Work For Us
Click "Apply" at the bottom of the page. If you have questions about applying for jobs, contact the job information line at 651-259-3637.
For additional information about the application process, go to http://www.mn.gov/careers.Contact
AN EQUAL OPPORTUNITY EMPLOYER
The State of Minnesota is an equal opportunity, affirmative action, and veteran-friendly employer. We are committed to providing culturally responsive services to all Minnesotans. The State of Minnesota recognizes that a diverse workforce is essential and strongly encourages qualified women, minorities, individuals with disabilities, and veterans to apply.
We will make reasonable accommodations to all qualified applicants with disabilities. If you are an individual with a disability who needs assistance or cannot access the online job application system, please contact the job information line at 651-259-3637 or email firstname.lastname@example.org. Please indicate what assistance you need.