Compliance Investigator - Consumer Protection (Medicaid Fraud Control Unit).

About the Unit

The Colorado Medicaid Fraud, Abuse, and Neglect Unit (MFANU) conducts civil and criminal investigations, litigation, and prosecution of fraudulent activity by Medicaid providers (such as hospitals, doctors, pharmacies, nursing homes, etc.) and of patient abuse (such as physical assault, sexual assault, homicide and embezzlement of patient trust funds). This unit receives multiple referrals and evaluates them to determine if they warrant further investigation and criminal prosecution in state court. Often, the unit acts as the lead investigative agency gathering information from partnering law enforcement and regulatory agencies, not limited to numerous local, state and federal agencies within the State of Colorado. This unit also receives investigations from other law enforcement agencies for subsequent prosecution. This unit provides training and technical assistance to law enforcement agencies within the State of Colorado related to Medicaid Fraud.

About the Position

The compliance investigator II conducts complex civil and criminal healthcare fraud investigations involving alleged violations of state and federal Medicaid laws. Independently evaluates allegations of fraud, abuse, and neglect; develops investigative strategies; analyzes complex financial, medical, and investigative information; and gathers, preserves, and evaluates evidence to support civil or criminal enforcement actions. Provides investigative recommendations to attorneys, special agents, analysts, and law enforcement partners throughout the investigative process, prepares investigative reports and litigation support materials, and may serve as the Medicaid Fraud Control Unit's Property and Evidence Manager by maintaining evidence and ensuring compliance with chain-of-custody requirements.

Responsibilities

Investigative/Case Prep

• Evaluate and follow up on complaints received through the Department's Medicaid Fraud Reporting Portal and other referral sources to determine investigative merit, jurisdiction, and appropriate investigative action.
• Conduct and coordinate complex civil and criminal investigations involving alleged violations of the Colorado Medicaid False Claims Act, the federal False Claims Act, and other applicable state and federal laws enforced by the Medicaid Fraud Control Unit.
• Analyze complex investigative, financial, medical, and operational information to identify potential healthcare fraud, Medicaid fraud, abuse, neglect, and other unlawful conduct; develop investigative strategies; and support civil and criminal enforcement actions.
• Collaborate with attorneys, special agents, analysts, paralegals, and other law enforcement partners to gather, analyze, and preserve evidence; determine whether conduct supports civil or criminal enforcement; and advance investigations through appropriate investigative and prosecutorial strategies.
• Conduct interviews of witnesses, victims, suspects, and other involved parties; research and obtain documentary, financial, medical, and electronic evidence; evaluate investigative findings; and prepare comprehensive reports, case summaries, and prosecutorial briefings.
• Independently assess complex and evolving investigative information, identify investigative leads and evidentiary gaps, make real-time investigative recommendations, and coordinate investigative activities to support successful case resolution.
• Serve as the Medicaid Fraud Control Unit's Property and Evidence Manager, when assigned, by maintaining evidence in accordance with chain-of-custody requirements, conducting inventories, updating procedures, training staff, and ensuring the secure retention and disposition of evidence.

Investigative Analysis and Intelligence Development

• Collect, evaluate, analyze, and synthesize complex investigative, financial, medical, and intelligence information from public records, criminal justice databases, Medicaid claims data, law enforcement systems, and other investigative sources.
• Conduct detailed financial and data analysis to identify fraudulent billing patterns, quantify fraud damages, calculate suspect liability, and distinguish between multiple types of fraudulent activity while eliminating duplicate claims and payments.
• Utilize investigative analysis techniques, including charting, timelines, link analysis, telephone toll analysis, search warrant return analysis, and other analytical methods to identify relationships, investigative leads, and patterns of unlawful conduct.
• Conduct interviews, gather investigative information, and collaborate investigative activities with special agents, attorneys, analysts, and external law enforcement agencies to develop investigative findings and determine appropriate civil or criminal enforcement strategies.
• Apply critical thinking, professional judgment, and inductive reasoning to evaluate investigative findings, develop investigative hypotheses, identify evidentiary gaps, and recommend additional investigative actions.
• Prepare comprehensive investigative reports, charts, presentations, and other analytical work products that clearly communicate investigative findings and support prosecutorial decision-making.
• Identify investigative trends, connections, and overlapping evidence across multiple investigations; communicate significant findings to investigative teams; and recommend new investigations when evidence indicates additional fraudulent activity or previously unidentified suspects.

Document Preparation & Report Writing

• Maintain, organize, and preserve investigative records, evidence, and large volumes of information within investigative case management systems to ensure the integrity, accessibility, and admissibility of records for civil and criminal proceedings.
• Analyze and synthesize investigative, financial, medical, and documentary evidence obtained from businesses, consumers, suspects, witnesses, employees, former employees, and other sources into clear, concise, and accurate investigative reports, affidavits, charts, presentations, spreadsheets, graphs, and other evidentiary work products.
• Prepare comprehensive case summaries that accurately document investigative findings, including exculpatory information, investigative methodologies, and supporting evidence for use by attorneys during charging decisions, settlement negotiations, administrative actions, and court proceedings.

Outreach & Education

• Engage in informational meetings and outreach to the public to educate them on the mission of the MFANU.
• Build relationships with other government agencies in Colorado and elsewhere using knowledge of the state's Medicaid statutes, providing them with assistance, guidance, and training when needed and requested.

Minimum Qualifications

Please document all relevant experience in detail on your application. Experience will not be inferred or assumed. Any part-time experience listed will be prorated.

Experience Only: Requires six (6) years of professional experience in investigation either as an investigator, investigative journalist, auditor or fraud specialist, or other field where you were responsible for conducting investigations. This experience must include review of initial complaints, follow up investigation, final recommendation, and further compliance.

OR Education And Experience: Requires a combination of full-time college course work from an accredited institute in criminal justice, public administration, or other closely related college course work AND/OR professional experience in investigation either as an investigator, investigative journalist, auditor or fraud specialist, or other field where you were responsible for conducting investigations totaling six years. This experience must include review of initial complaints, follow up investigation, final recommendation, and further compliance. If substituting education for experience, transcripts must be provided at time of application. Candidates possessing a foreign degree must submit a translation (evaluation) of the degree from an accredited institution, such as The National Association of Credential Evaluations Services in order to be given credit for the degree.

Required Competencies

• Ability to independently conduct complex civil and criminal investigations from complaint/referral through case development, including determining investigative merit, identifying leads and evidentiary gaps, developing investigative strategies, and determining appropriate investigative actions.
• Strong ability to analyze and synthesize complex financial, medical, billing, claims, electronic, and investigative information; identify patterns, discrepancies, relationships, and potential unlawful conduct; develop investigative hypotheses; and draw well-supported conclusions.
• Ability to exercise independent professional judgment when evaluating allegations and evidence, determining investigative priorities and methodologies, assessing the reliability and evidentiary value of information, and recommending additional investigative or enforcement action.
• Ability to analyze complex financial and claims data, identify fraudulent billing patterns or questionable transactions, quantify potential damages or liability, and organize large datasets using spreadsheets, databases, charts, timelines, link analysis, or other investigative analytical methods.

Preferred Qualifications

In addition to the minimum qualifications, the preferred applicant will also demonstrate and clearly describe the following skills and experience in their job application:

• Experience conducting complex investigations, including independently evaluating allegations, developing investigative strategies, identifying investigative leads, and determining appropriate investigative actions.

This response is AI-generated, for reference only.