Location: Nashville,NC, USA
Food and Nutrition and Program Integrity experience preferred. NC Fast experience required.
A. Primary Purpose of the Position
The primary purpose of this position is to investigate and gather facts to determine if proper
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 the 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.
B. Work Schedule
The regular working hours in this position are from 8:00 AM until 5:00 PM - Monday
through Friday except holidays. There is no rotation of shifts. This Investigator may be called
upon to revise the scheduled hours for any number of reasons, including being involved in a
court case past the normal work hours.
C. 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.A. Investigation Procedures 50 %
Investigation procedures include, but may not be limited to:
1. 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.
2. 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 Social 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.
3. Assistance may be requested by the USDA to investigate retail abuse in the Food and
Nutrition Services program.
4. 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.
a). Adult Medicaid
b). Family and Children's Medicaid
c). All other public assistance programs
5. 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.
6. Key all fraud referrals into NC FAST and in-house tracking system timely.
7. Study, take all online courses in The Learning Gateway and learn all NC FAST
procedures as Program Integrity is fully implemented into NC FAST.
8. 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.
9. Work in (LIEAP) program annually taking applications and determining program
eligibility in NC FAST system.
10. Conduct second party reviews as called upon by Food and Nutrition and both Medicaid
departments returning completed second party review forms weekly to supervisors.
11. Process spin offs for all agency programs as it relates to overpayments or underpayments
being established.
12. Refer all provider reported cases of fraud to the state maintaining appropriate
documentation of how the report was made.
13. Act as agency's Local Hearing Scheduler, scheduling all interagency hearing officers and
notifying appropriate staff timely, officer assigned to case, supervisor and worker.
14. Work 90% to 95% independently researching policy and procedures as it relates to
substantiating or unsubstantiating cases of fraud.
15. Perform additional job duties subjected to be added as needed.
B. Court and Administrative Hearing 20%
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 county attorney with a
recommendation of action such as settlement or 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 Social Services Board, summaries must be prepared in a factual and direct
manner, and must contain complete and concise information. The Investigator must include
in the case summary the alleged act of fraud, verifications obtained and time period involved, client's background information and a recommendation to the Board. 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.
C. Collections 12%
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.
D. Field Investigations 7%
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.
E. Telephone 5%
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.
F. Office Visits 2%
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 give the opportunity to share and gain information in a private and comfortable setting.
G. Conferences 2%
The Adult Medicaid Unit conferences are scheduled monthly and individual conferences are
as needed and requested.
H. Miscellaneous 2%
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.
Other Position Characteristics
A. 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.
B. 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. Inaccuracy in the
case preparation may leave the agency vulnerable to class action and/or uncollected funds.
C. 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.
D. 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.
E. 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.
F. 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.