Claims Investigator

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Functional Title: Claims Investigator

Job Title: Investigator II

Agency: Health & Human Services Comm

Department: Benefits Program Integrity

Posting Number: 18365

Closing Date: 07/09/2026

Posting Audience: Internal and External

Occupational Category: Business and Financial Operations

Salary Range: $3,409.83 - $4,252.00

Pay Frequency: Monthly

Salary Group: TEXAS-B-16

Shift: Day

Additional Shift: Days (First)

Telework: Eligible for Telework

Travel: Up to 20%

Regular/Temporary: Regular

Full Time/Part Time: Full time

FLSA Exempt/Non-Exempt: Nonexempt

Facility Location:

Job Location City: EL PASO

Job Location Address: 401 FRANKLIN AVE

Other Locations: El Paso

MOS Codes: 5805,5813,5819,5821,5822,7596,8012,14N,14NX,183X,1D7X1,1N0X1,1S0X1,250X,311A,31A,31B,31D,31PX,351L

351M,35A,35L,35M,3E7X1,3P0X1,43HX,4B0X1,4E0X1,5I0,649X,683X,71SX,749X,783X,89D,89E,EOD,INV,IS,IV,LN

MA,ME,MLES,MSSD,MSSE,MSSR,MST,OAP12,OAP14

Brief Job Description

The Office of Inspector General (OIG) Benefits Program Integrity (BPI) Claims Investigator II reports to the BPI unit manager/director. BPI Claims Investigators perform moderately complex investigative work regarding recipients of HHS programmatic services, such as Medicaid; the Children's Health Insurance Program (CHIP); the Supplemental Nutrition Assistance Program (SNAP); Temporary Assistance for Needy Families (TANF); and the Women, Infants, and Children's (WIC) program. The BPI Claims Investigator III is responsible for investigating referrals of fraud, waste, and abuse by HHS clients; conducting thorough research and evidence gathering activities; and determining whether the information collected represents a violation of program laws, rules, or regulations according to applicable evidentiary standards.

The Claims Investigator II ensures that allegations of client fraud, waste, or abuse are investigated according to law, regulations, agency policies, and professional standards. The position reviews and analyzes records and reports from multiple agency, state, and federal databases; collaborates with both internal and external stakeholders to obtain verification and evidence; understands and applies relevant eligibility requirements; and calculates and establishes overpayment claims. The position obtains business records affidavits, submits subpoenas, and coordinates with law enforcement or other state and federal entities. The Claims Investigator may present cases at both Fair Hearings and Administrative Disqualification Hearings.

The position may assist with preparing and presenting training, suggest improvements to BPI's investigative processes to improve efficiency and promote program integrity, and perform other related duties as assigned. Works under general supervision with limited latitude for the use of initiative and independent judgment as governed by policy and procedures.

Essential Job Functions

30% Researches, conducts, collects evidence, reviews records, and examines potential eligibility discrepancies through multiple agency, state, and federal systems to determine program compliance and identify fraud. Interacts and exchanges information with various internal and external stakeholders; coordinates with law enforcement organizations and other state and federal agencies; and contacts and interviews witnesses and complainants as appropriate to verify recipient case information and evaluate allegations of fraud, waste, and abuse. Follows HHS and OIG policies and procedures and adheres to applicable investigative standards and evidentiary protocols.

30% Evaluates, summarizes, and documents investigative findings and prepares detailed, factual investigative case reports. Calculates overpayments and establishes overpayment claims to recover unauthorized benefit payments. Prepares correspondence to clients detailing investigative outcomes and provides testimony and presents case file information and evidence at administrative hearings.

30% Maintains clear investigative documentation and implements well-organized electronic filing and documentation systems. Employs organizational techniques to manage a high volume of investigations at various stages simultaneously. Suggests process improvements that increase efficiency and effectiveness of investigative activities and documentation. Adheres to confidentiality requirements and records retention schedules.

10% Assists in preparing and delivering training, may assist with policy and procedure or job aid development and review, and may provide input into and assist in testing automated system enhancements or fixes.

Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.

Knowledge, Skills, and Abilities

• Knowledge of office management and administrative procedures.
• Knowledge of investigative principles, techniques, and standards.
• Knowledge of administrative hearing procedures and practices.
• Knowledge of state and federal laws, regulations, and policies related to health and human services.
• Knowledge of HHS social services programs and eligibility requirements.
• Experience in using automated systems for documentation, research, and tracking.
• Skill in communicating effectively both orally and in writing.
• Skill in conducting legal research and analysis.
• Skill in the use of computer/laptop equipment and applicable software applications.
• Skill in performing budget calculations and using mathematical formulas.
• Skill in handling multiple competing priorities and meeting deadlines.
• Ability to establish and maintain effective working relationships with others.
• Ability to organize research and gather evidence.
• Ability to interpret and apply laws and regulations.
• Ability to plan, organize, and conduct investigations.
• Ability to conduct investigative interviews.
• Ability to comprehend agency policies and guidelines and determine employee or recipient compliance.
• Ability to compile, evaluate findings, and present information relevant to investigations.
• Ability to use facts to prepare high-quality reports with strong attention to detail.
• Ability to testify in hearings or court proceedings.
• Ability to develop and present training to others.

Registration or Licensure Requirements

Current Driver's License

Initial Selection Criteria

Graduation from an accredited high school or GED. Graduation from an accredited four-year college or university with major coursework in business, public administration, criminal justice, or a field related to the assignment OR three years' experience in applying SNAP, TANF, and Medicaid policies, procedures, and regulations is required. Experience and education may be substituted on a year-for-year basis.

Additional Information

This position requires 20% travel.

The OIG is responsible for preventing, detecting, auditing, inspecting, reviewing and investigating fraud, waste and abuse in the provision of HHS in Medicaid and other HHS programs. Potential employees of OIG are subject to criminal background checks in accordance with the HHS Human Resources policy. Selected applicants must complete a national fingerprint-based criminal background check through the Texas Department of Public Safety (TDPS) and Federal Bureau of Investigations (FBI) to determine if they have criminal history record information that constitutes a bar to employment.

Any employment offer is contingent upon available budgeted funds. The offered salary will be determined in accordance with budgetary limits and the requirements of HHSC Human Resources Manual Chapter 7.

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Active Duty, Military, Reservists, Guardsmen, and Veterans:

Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to those listed in this posting. All active-duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information please see the Texas State Auditor's Job Descriptions, Military Crosswalk and Military Crosswalk Guide at Texas State Auditors Office - Job Descriptions.

ADA Accommodations:

In compliance with the Americans with Disabilities Act (ADA), HHSC and DSHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the on-line application, contact the HHS Employee Service Center at 1-888-894-4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview.

Pre-Employment Checks and Work Eligibility:

Depending on the program area and position requirements, applicants selected for hire may be required to pass background and other due diligence checks.

HHSC uses E-Verify. You must bring your I-9 documentation with you on your first day of work. Download the I-9 Form

Telework Disclaimer:

This position may be eligible for telework. Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business needs.