Nash County
Income Maintenance Investigator II
Nash County, Nashville, North Carolina, United States, 27856
Food and Nutrition and Program Integrity experience preferred. NC Fast experience required.
Primary Purpose of the Position The primary purpose of this position is to investigate and gather facts to determine if improper determination of eligibility for public assistance cases such as Medicaid, Food and Nutrition, WFFA, CIP and LIEAP have been implemented and/or if fraudulent practices have occurred. When an error indicates potential client fraud, the Income Maintenance Investigator is responsible for investigating the case and determining the appropriate course of action required to resolve the case referral. The Income Maintenance Investigator must also evaluate suspected fraud cases for possible court action, prepare the case for court, represent the agency in court and interact with the judicial process. Responsibilities also include agency representation at administrative hearings, collections, and recoupments. This worker is a part of the Adult Medicaid unit and is supervised by the Adult Medicaid Long Term Care/Program Integrity Supervisor.
Work Schedule The regular working hours in this position are from 8:00 AM until 5:00 PM – Monday through Friday, except holidays. This Investigator may be called upon to work outside the scheduled business hours for any number of reasons, including being involved in a court case past the normal work hours or meeting with a client that comes into the building just before 5:00 p.m.
Change in Responsibilities or Organizational Relationships Fraud investigation procedures are becoming more sophisticated due to retinal imaging and other automated enhancements such as Tax Intercept, Food and Nutrition automatic deduction, EBT Edge, Medicaid Profiles, Lexis Nexis, NC FAST, EPICS and online verifications. It is anticipated that these changes and improvements will require additional training and staffing.
Investigation Procedures Investigation procedures include, but may not be limited to:
Gathering of facts from reliable sources such as agency staff, case records, employers, hospitals, post offices and other government agencies such as Department of Motor Vehicles, Social Security Administration, Employment Security Commission, Tax Departments, Registers of Deeds, Health Departments, USDA, Alien Registration office, Law Enforcement Agencies, lawyers, rental agencies, banks, collaterals and many other community resources. This information may be gathered by personal interviews, telephone, facsimile, news reports and/or newspapers, and social media.
If fraudulent acts have occurred, the fraud investigator is responsible for re‑constructing the case to determine the amount of overpayment. The investigator must also determine if the case should be referred to the Human Services Board for approval of Investigator's recommendation - that may include court action. Active cases must be investigated timely in order to assure accurate ongoing assistance.
Assistance may be requested by the USDA to investigate retail abuse in the Food and Nutrition Services program.
Manage and complete twenty (20) FRR and BEER Reports weekly in ensuring information on file is reported accurately. Turn in number of reports worked weekly and completed to department supervisors. Investigate all cases for overpayments, underpayments, complete fraud referrals and establish in NC FAST processing within required time frames of 180 days. Return reports to department supervisors for state/security compliance for the following programs upon completion.
Adult Medicaid
Family and Children’s Medicaid
All other public assistance programs
Manage Quarterly Interstate Match Reports to ensure non‑dual participation across state lines for both Medicaid Programs and return to department supervisors timely. Create potential fraud referrals and manage in NC FAST and in‑house tracking timely.
Key all fraud referrals into NC FAST and in‑house tracking system timely.
Study, take all online courses in The Learning Gateway and learn all NC FAST procedures as Program Integrity is fully implemented into NC FAST.
Manage caseloads due to vacant districts and or shortage of staff due to short term or extended leave and serve as potential back‑up for Food and Nutrition and all Medicaid programs, PLA, SA, CAP, LTC and Family and Children’s Medicaid.
Conduct second party reviews as called upon by Food and Nutrition and both Medicaid departments returning completed second party review forms weekly to supervisors.
Process spin offs for all agency programs as it relates to overpayments or underpayments being established.
Refer all provider reported cases of fraud to the state maintaining appropriate documentation of how the report was made.
Act as agency’s Local Hearing Scheduler, scheduling all interagency hearing officers and notifying appropriate staff timely, officer assigned to case, supervisor and worker.
Work 90% to 95% independently researching policy and procedures as it relates to substantiating or unsubstantiating cases of fraud.
Perform additional job duties subjected to be added as needed.
Court and Administrative Hearing Upon receipt, suspected fraud referrals must be logged and a case file established. Once the case has been investigated and findings documented, the client is contacted for an interview.
During this interview, the Investigator will explain the suspected fraud findings, the action being taken and answer any of the client's questions. The discussion will also include the course of action necessary to resolve the case. Unfounded cases may involve client responsible overpayments, county‑responsible overpayments or not existing overpayments.
The Investigator will assess any statements from the client regarding the suspected fraudulent act along with the client's willingness to cooperate in repayment.
The case may be referred to executive management and agency attorney with a recommendation of action such as settlement, court or if the approval of executive management is not required, the case may be taken directly to court. When cases are to be taken to the Human Services Board, summaries must be prepared in a factual and direct manner, and must contain complete and concise information. The Investigator must then respond to the recommendation of the Board by proceeding with court action or making an arrangement for repayment by the client. This process requires many methods of budgeting – using the required forms for the particular program and the available automation – when possible. [Example – WFFA budgets can be computed online, while Food and Nutrition, Adult and Children’s Medicaid programs many have different budgets for their programs and all of these must be done manually. The DSS‑1682 is prepared to calculate over‑issuance of Food and Nutrition Services benefits.]
The Investigator is responsible for agency representation through proper court action. This includes: preparation and issuance of criminal warrants, appearing in district court, negotiating with district and defense attorneys, conferring with judges and court clerk and testifying in court as the State's witness. Testimony before the Grand Jury is required when the District Attorney's office refers felony cases for possible felony indictments. If a true bill of indictment is issued, the Investigator is required to testify in superior court as a witness for the State, either before the judge and/or jury. In cases that involve a client's failure to comply with a court order, court testimony may be required regarding the amount paid and the client's inability or ability to repay the money owed. This position requires a great deal of autonomy in decision‑making regarding involvement in the administrative hearing and judicial process.
Collections The Income Maintenance Investigator must enforce and administer collection actions and procedures, including: sending delinquent notices, posting claim payments, notifying the Clerk of Court to issue show cause orders of non‑compliance, administering information to data entry for tax intercept and following up with letters to clients. The Investigator assists with entering payments into NC FAST, completing and balancing food stamp quarterly collections reports, reviewing and updating printouts and logs for collection and/or disqualifications and transferring claims that move out of county or state to proper collecting agency. The Investigator must follow through with State and inter‑state matches in order to deter fraud. All attempts must be made to locate any out of state persons. Required state office forms and reports including 4972 report, must be completed. Client responsible overpayments, collections and repayment arrangements is essential and a must for accurate records of payments. Payments must be balanced, case status must be monitored, and necessary action taken to assure collection. Automation is continuing to enhance collection activities.
Field Investigations Announced and unannounced home visits are made to interview clients and collaterals and sometimes required in order to establish facts. Field visits are expected to increase due to increases in suspected fraud referrals and front‑end investigations. Some of the reasons for this could be sited – selling and trading drugs for Food and Nutrition benefits or use of EBT card, clients receiving dual benefits – Medicaid, WFFA and/or Food and Nutrition, both here in North Carolina and in another state.
Telephone Many telephone calls are received daily, and may involve lengthy calls from anonymous persons, angry clients, taxpayers, employers, court personnel, contacts from other states and counties, as well as USDA personnel. Many calls are also made daily to collaterals, clients, court personnel, attorneys, workers in State Office and contacts in other states and counties, etc.
Office Visits Office visits may be made by clients, client's representatives or attorneys, persons making referrals and staff members. The visits are necessary to obtain statements, provide information regarding fraud consequences, obtain verification of information and documents, or negotiate repayment of money owed. Privacy is of utmost importance, therefore the visitor is given the opportunity to share and gain information in a private and comfortable setting.
Conferences The Adult Medicaid Unit conferences are scheduled monthly and individual conferences are also held month, and more frequent as needed and requested.
Miscellaneous New policy and regulations, Job Aids and communications must be reviewed, including unit, individual and supervisory study and/or review. Attendance may be required to network regional meetings and training. Any necessary documents should be filed in case records. Creative planning time may be used.
Section III – Other Position Characteristics Accuracy required in work – Accuracy in investigations is vital. Calculations of overpayment must be correct since this is the amount that will be required by the court for repayment. Collections are also important and must be accurate and precise before preparing quarterly reports, case prosecution must be consistent and prepared according to manual policy and guidelines of the court system. Summaries must be neat and prepared according to requirements of the agency and the court.
Consequence of Error – Failure to practice accuracy will result in the agency not being able to collect funds which the client had received through misrepresentation. If the Investigator does not pursue the correct course of action in resolving suspected fraud (or fraud) cases, the integrity of the agency may be at risk; embarrassment and ineffectiveness in the courtroom may also develop if the Investigator has not properly prepared the case.
Instruction Provided to Employee – Instructions may be written or oral and will usually be received from the direct Supervisor for the Investigator and in this case – it is the Program Integrity Supervisor. State Office Broadcast Messages and other directives are provided as well as letters, memorandums, administrative letters and notice of manual changes.
Guides, Regulations, Policies, References and Job Aids used by Investigator – Policy/program manuals are vital to worker in this position. WFFA, Medicaid Manuals (both Adult and Family & Children), Food and Nutrition Manuals, Fraud Investigators Handbook, Service Manuals, Dear County letters, printouts, collection data, repayment schedules, reports, etc. are required to be able to perform the duties of this position. The Investigator must be familiar with legal procedures and statutory regulations governing the administration of justice in income maintenance fraud cases.
Supervision Received by Employee – The Investigator in this position has constant contact with agency staff, as well as the community at large – employers, collateral sources, insurance companies, post office employees, DMV personnel, tax offices, hospitals, doctors, schools, law enforcement, court personnel, attorneys and other local and government agencies in order to gain and verify information regarding possible fraud investigations.
Employee will be expected to work in emergency shelters and/or perform related disaster tasks and perform other reasonable tasks requested by their immediate Supervisor, Deputy Director and/or Director.
The Investigator should have good communications skills, good comprehension skills, good concentration level and good listening skills. The Investigator should also have a good working knowledge of Social Services' programs and the agency expectations. Mathematical skills are a must in this position. The Investigator should maintain effective working relationship with all staff, general public and the judicial system.
Required Minimum Training – An Associate Degree in Human Services Technology, Social Services Associate Degree, Paralegal Technology, Criminal Justice, Business Administration Degree or Secretarial Science Degree or closely related curriculum and two years of experience as an Income Maintenance Caseworker or Investigator; or, graduation from high school and three years’ experience as an Income Maintenance Caseworker or Income Maintenance Investigator; or graduation from high school and two years of investigative experience in credit, legal or law enforcement work plus eighteen months experience as an Income Maintenance Caseworker or Income Maintenance Investigator.
Additional Training/Experience – Public relations experience is preferred as well as involvement with the judicial system. The ability to present information orally and written.
License or Certification Required by Statue or Regulation – A valid North Carolina Driver's License.
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Primary Purpose of the Position The primary purpose of this position is to investigate and gather facts to determine if improper determination of eligibility for public assistance cases such as Medicaid, Food and Nutrition, WFFA, CIP and LIEAP have been implemented and/or if fraudulent practices have occurred. When an error indicates potential client fraud, the Income Maintenance Investigator is responsible for investigating the case and determining the appropriate course of action required to resolve the case referral. The Income Maintenance Investigator must also evaluate suspected fraud cases for possible court action, prepare the case for court, represent the agency in court and interact with the judicial process. Responsibilities also include agency representation at administrative hearings, collections, and recoupments. This worker is a part of the Adult Medicaid unit and is supervised by the Adult Medicaid Long Term Care/Program Integrity Supervisor.
Work Schedule The regular working hours in this position are from 8:00 AM until 5:00 PM – Monday through Friday, except holidays. This Investigator may be called upon to work outside the scheduled business hours for any number of reasons, including being involved in a court case past the normal work hours or meeting with a client that comes into the building just before 5:00 p.m.
Change in Responsibilities or Organizational Relationships Fraud investigation procedures are becoming more sophisticated due to retinal imaging and other automated enhancements such as Tax Intercept, Food and Nutrition automatic deduction, EBT Edge, Medicaid Profiles, Lexis Nexis, NC FAST, EPICS and online verifications. It is anticipated that these changes and improvements will require additional training and staffing.
Investigation Procedures Investigation procedures include, but may not be limited to:
Gathering of facts from reliable sources such as agency staff, case records, employers, hospitals, post offices and other government agencies such as Department of Motor Vehicles, Social Security Administration, Employment Security Commission, Tax Departments, Registers of Deeds, Health Departments, USDA, Alien Registration office, Law Enforcement Agencies, lawyers, rental agencies, banks, collaterals and many other community resources. This information may be gathered by personal interviews, telephone, facsimile, news reports and/or newspapers, and social media.
If fraudulent acts have occurred, the fraud investigator is responsible for re‑constructing the case to determine the amount of overpayment. The investigator must also determine if the case should be referred to the Human Services Board for approval of Investigator's recommendation - that may include court action. Active cases must be investigated timely in order to assure accurate ongoing assistance.
Assistance may be requested by the USDA to investigate retail abuse in the Food and Nutrition Services program.
Manage and complete twenty (20) FRR and BEER Reports weekly in ensuring information on file is reported accurately. Turn in number of reports worked weekly and completed to department supervisors. Investigate all cases for overpayments, underpayments, complete fraud referrals and establish in NC FAST processing within required time frames of 180 days. Return reports to department supervisors for state/security compliance for the following programs upon completion.
Adult Medicaid
Family and Children’s Medicaid
All other public assistance programs
Manage Quarterly Interstate Match Reports to ensure non‑dual participation across state lines for both Medicaid Programs and return to department supervisors timely. Create potential fraud referrals and manage in NC FAST and in‑house tracking timely.
Key all fraud referrals into NC FAST and in‑house tracking system timely.
Study, take all online courses in The Learning Gateway and learn all NC FAST procedures as Program Integrity is fully implemented into NC FAST.
Manage caseloads due to vacant districts and or shortage of staff due to short term or extended leave and serve as potential back‑up for Food and Nutrition and all Medicaid programs, PLA, SA, CAP, LTC and Family and Children’s Medicaid.
Conduct second party reviews as called upon by Food and Nutrition and both Medicaid departments returning completed second party review forms weekly to supervisors.
Process spin offs for all agency programs as it relates to overpayments or underpayments being established.
Refer all provider reported cases of fraud to the state maintaining appropriate documentation of how the report was made.
Act as agency’s Local Hearing Scheduler, scheduling all interagency hearing officers and notifying appropriate staff timely, officer assigned to case, supervisor and worker.
Work 90% to 95% independently researching policy and procedures as it relates to substantiating or unsubstantiating cases of fraud.
Perform additional job duties subjected to be added as needed.
Court and Administrative Hearing Upon receipt, suspected fraud referrals must be logged and a case file established. Once the case has been investigated and findings documented, the client is contacted for an interview.
During this interview, the Investigator will explain the suspected fraud findings, the action being taken and answer any of the client's questions. The discussion will also include the course of action necessary to resolve the case. Unfounded cases may involve client responsible overpayments, county‑responsible overpayments or not existing overpayments.
The Investigator will assess any statements from the client regarding the suspected fraudulent act along with the client's willingness to cooperate in repayment.
The case may be referred to executive management and agency attorney with a recommendation of action such as settlement, court or if the approval of executive management is not required, the case may be taken directly to court. When cases are to be taken to the Human Services Board, summaries must be prepared in a factual and direct manner, and must contain complete and concise information. The Investigator must then respond to the recommendation of the Board by proceeding with court action or making an arrangement for repayment by the client. This process requires many methods of budgeting – using the required forms for the particular program and the available automation – when possible. [Example – WFFA budgets can be computed online, while Food and Nutrition, Adult and Children’s Medicaid programs many have different budgets for their programs and all of these must be done manually. The DSS‑1682 is prepared to calculate over‑issuance of Food and Nutrition Services benefits.]
The Investigator is responsible for agency representation through proper court action. This includes: preparation and issuance of criminal warrants, appearing in district court, negotiating with district and defense attorneys, conferring with judges and court clerk and testifying in court as the State's witness. Testimony before the Grand Jury is required when the District Attorney's office refers felony cases for possible felony indictments. If a true bill of indictment is issued, the Investigator is required to testify in superior court as a witness for the State, either before the judge and/or jury. In cases that involve a client's failure to comply with a court order, court testimony may be required regarding the amount paid and the client's inability or ability to repay the money owed. This position requires a great deal of autonomy in decision‑making regarding involvement in the administrative hearing and judicial process.
Collections The Income Maintenance Investigator must enforce and administer collection actions and procedures, including: sending delinquent notices, posting claim payments, notifying the Clerk of Court to issue show cause orders of non‑compliance, administering information to data entry for tax intercept and following up with letters to clients. The Investigator assists with entering payments into NC FAST, completing and balancing food stamp quarterly collections reports, reviewing and updating printouts and logs for collection and/or disqualifications and transferring claims that move out of county or state to proper collecting agency. The Investigator must follow through with State and inter‑state matches in order to deter fraud. All attempts must be made to locate any out of state persons. Required state office forms and reports including 4972 report, must be completed. Client responsible overpayments, collections and repayment arrangements is essential and a must for accurate records of payments. Payments must be balanced, case status must be monitored, and necessary action taken to assure collection. Automation is continuing to enhance collection activities.
Field Investigations Announced and unannounced home visits are made to interview clients and collaterals and sometimes required in order to establish facts. Field visits are expected to increase due to increases in suspected fraud referrals and front‑end investigations. Some of the reasons for this could be sited – selling and trading drugs for Food and Nutrition benefits or use of EBT card, clients receiving dual benefits – Medicaid, WFFA and/or Food and Nutrition, both here in North Carolina and in another state.
Telephone Many telephone calls are received daily, and may involve lengthy calls from anonymous persons, angry clients, taxpayers, employers, court personnel, contacts from other states and counties, as well as USDA personnel. Many calls are also made daily to collaterals, clients, court personnel, attorneys, workers in State Office and contacts in other states and counties, etc.
Office Visits Office visits may be made by clients, client's representatives or attorneys, persons making referrals and staff members. The visits are necessary to obtain statements, provide information regarding fraud consequences, obtain verification of information and documents, or negotiate repayment of money owed. Privacy is of utmost importance, therefore the visitor is given the opportunity to share and gain information in a private and comfortable setting.
Conferences The Adult Medicaid Unit conferences are scheduled monthly and individual conferences are also held month, and more frequent as needed and requested.
Miscellaneous New policy and regulations, Job Aids and communications must be reviewed, including unit, individual and supervisory study and/or review. Attendance may be required to network regional meetings and training. Any necessary documents should be filed in case records. Creative planning time may be used.
Section III – Other Position Characteristics Accuracy required in work – Accuracy in investigations is vital. Calculations of overpayment must be correct since this is the amount that will be required by the court for repayment. Collections are also important and must be accurate and precise before preparing quarterly reports, case prosecution must be consistent and prepared according to manual policy and guidelines of the court system. Summaries must be neat and prepared according to requirements of the agency and the court.
Consequence of Error – Failure to practice accuracy will result in the agency not being able to collect funds which the client had received through misrepresentation. If the Investigator does not pursue the correct course of action in resolving suspected fraud (or fraud) cases, the integrity of the agency may be at risk; embarrassment and ineffectiveness in the courtroom may also develop if the Investigator has not properly prepared the case.
Instruction Provided to Employee – Instructions may be written or oral and will usually be received from the direct Supervisor for the Investigator and in this case – it is the Program Integrity Supervisor. State Office Broadcast Messages and other directives are provided as well as letters, memorandums, administrative letters and notice of manual changes.
Guides, Regulations, Policies, References and Job Aids used by Investigator – Policy/program manuals are vital to worker in this position. WFFA, Medicaid Manuals (both Adult and Family & Children), Food and Nutrition Manuals, Fraud Investigators Handbook, Service Manuals, Dear County letters, printouts, collection data, repayment schedules, reports, etc. are required to be able to perform the duties of this position. The Investigator must be familiar with legal procedures and statutory regulations governing the administration of justice in income maintenance fraud cases.
Supervision Received by Employee – The Investigator in this position has constant contact with agency staff, as well as the community at large – employers, collateral sources, insurance companies, post office employees, DMV personnel, tax offices, hospitals, doctors, schools, law enforcement, court personnel, attorneys and other local and government agencies in order to gain and verify information regarding possible fraud investigations.
Employee will be expected to work in emergency shelters and/or perform related disaster tasks and perform other reasonable tasks requested by their immediate Supervisor, Deputy Director and/or Director.
The Investigator should have good communications skills, good comprehension skills, good concentration level and good listening skills. The Investigator should also have a good working knowledge of Social Services' programs and the agency expectations. Mathematical skills are a must in this position. The Investigator should maintain effective working relationship with all staff, general public and the judicial system.
Required Minimum Training – An Associate Degree in Human Services Technology, Social Services Associate Degree, Paralegal Technology, Criminal Justice, Business Administration Degree or Secretarial Science Degree or closely related curriculum and two years of experience as an Income Maintenance Caseworker or Investigator; or, graduation from high school and three years’ experience as an Income Maintenance Caseworker or Income Maintenance Investigator; or graduation from high school and two years of investigative experience in credit, legal or law enforcement work plus eighteen months experience as an Income Maintenance Caseworker or Income Maintenance Investigator.
Additional Training/Experience – Public relations experience is preferred as well as involvement with the judicial system. The ability to present information orally and written.
License or Certification Required by Statue or Regulation – A valid North Carolina Driver's License.
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