State of Maryland

A Medical Payment Investigator III is the advanced level of technical investigatory work in the Division of Field Investigation, Medical Care Programs, Maryland Department of Health.   Employees in this classification conduct investigations of allegations of Medical Assistance fraud which involve possible prosecution, recovery of Medical Assistance funds, and the discontinuance of Medical Assistance being fraudulently received.  The work of this classification involves the use of investigative procedures that are at times, complex, requiring analysis and evaluation of documents and the conduct of involved and technical interviews; facts ascertained through analysis of documents, research, and interviews are summarized in presentations to appropriate authorities because high quality, cogent, well-structured reports and synopses are needed to prosecute cases.  Employees in this classification conduct a variety of investigations such as Medical Assistance Provider fraud, which involves complicated matters such as double billing, overcharging, rebates, kickbacks and other fraudulent practices.  Employees in this classification present cases to State’s Attorneys, may be required to testify before Grand Juries and Circuit Courts but do not supervise other positions.

Employees in this classification receive general supervision from the Chief, Division of Field Investigation.  Employees handle more complicated investigatory work.  Employees must be able to carry a case from conception through prosecution with the bare minimum of supervision, and may be responsible for directing other investigators in major cases.  Work is evaluated through conferences and review of reports in terms of quality, timeliness and completeness of assigned investigations.

Positions in this classification are evaluated by using the classification job evaluation methodology.  The use of this method involves comparing the assigned duties and responsibilities of a position to the job criteria found in the Nature of Work and Examples of Work sections of the class specification.

The Medical Payments Investigator I, Medical Payments Investigator II and Medical Payments Investigator III are differentiated on the basis of degree of supervisory control exercised by the supervisor over these employees.  The Medical Payments Investigator performs duties under close supervision at times and under moderate supervision at other times depending on the complexity of the specific duty being performed.  The Medical Payments Investigator II performs the full range of duties under general supervision.  The Medical Payments Investigator III performs advanced level work by carrying cases from conception through prosecution with the bare minimum of supervision, and may be responsible for directing other Medical Payments Investigators in major cases. The Medical Payments Investigator III is differentiated from the Medical Payments Investigator Supervisor in that the Medical Payments Investigator Supervisor has supervisory responsibility for lower-level Medical Payments Investigators.

Conducts investigations involving fraud by recipients of Medical Assistance in such areas as false statements on the application for assistance and failure to disclose assets or income, or changes in economic status; and by providers of Medical Assistance in such areas as overcharging, billing for services not provided, duplicate billing for the same services, kickbacks, rebates and other fraudulent practices; \

Determines financial condition of recipient or relative;

Obtains signed statements where warranted;

Prepares reports of completed investigations of such quality that a State’s Attorney can proceed with prosecution or action to recover funds without any additional investigation being necessary;

Presents cases in a clear, logical concise manner to Federal and State’s Attorney for prosecutive opinions;

Testifies before Grand Juries and in trials;

Maintains records of all investigations;

Performs reviews and analyses of documents submitted for payment or applications for assistance to detect fraudulent practices or patterns;

May perform limited supervisory duties;

May assist supervisor in general field duties;

Performs other related duties.

Knowledge of modern business methods;

Knowledge of modern interviewing and investigative techniques;

Knowledge of elementary legal processes;

Ability to understand, interpret and explain laws, rules and regulations, procedures and statutory requirements;

Ability to make arithmetic computations with accuracy;

Ability to ascertain facts by personal contact and observation;

Ability to select relevant and appropriate information;

Ability to prepare clear and accurate reports;

Ability to deal with the public with tact, understanding, fairness and good judgment;

Ability to maintain confidentiality;

Ability to conduct oneself in a professional manner at all times.

Education:   Graduation from an accredited high school or possession of a high school equivalency certificate.

Experience: Five years of full-time experience, or its equivalent, in a combination of the following areas of work in a public or private organization; claims, credit or administrative investigations; police or licensed private detective work; law enforcement; determination of eligibility for licenses. Two years of the required experience must have been in investigations of Medical Assistance frauds.

Notes:

1. Candidates may substitute education at an accredited college or university on a year-for-year basis for up to two years of the general experience.

2. Candidates may substitute U.S. Armed Forces military service experience as a non-commissioned officer in Law Enforcement or Investigation classifications or Law Enforcement or Investigation specialty codes in the Investigation field of work on a year-for-year basis for the required experience.  

1. Employees in this classification may be required to have access to and operate an automobile.  Standard mileage allowance will be paid.

2. Employees in this classification are subject to call-in and, therefore, will be required to provide the employer with a phone number where they can be reached.

Class specifications are broad descriptions covering groups of positions used by various State departments and agencies. Position descriptions maintained by the using department or agency specifically address the essential job functions of each position.

This is a Skilled Service classification in the State Personnel Management System.  All positions in this classification are Skilled Service positions.  Some positions in Skilled Service classifications may be designated Special Appointment in accordance with the State Personnel and Pensions Article, Section 6-405, Annotated Code of Maryland.

This classification is assigned to Bargaining Unit C- Regulatory, Inspection and Licensure classes.  As provided by State Personnel and Pensions Article, Section 3-102, special appointment, temporary, contractual, supervisory, managerial, and confidential employees are excluded from collective bargaining. Additionally, certain executive branch agencies are exempt from collective bargaining and all positions in those agencies are excluded from collective bargaining.

Employees in this classification are eligible to receive overtime compensation.  An employee who works more than the normal workweek is entitled to be compensated for that overtime, as provided by the State Personnel and Pensions Article, Section 8-305.