Payment Integrity Investigator - Must Reside in Colorado

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Department

Job Summary
Under minimal supervision this position is responsible for detecting and investigating alleged or suspected fraud, waste, and/or abuse (FWA) by providers or enrolled members. As an investigator, you will conduct various activities to support Denver Health Medical Plan's (DHMP) FWA prevention and detection program.
Essential Functions:

• Conduct proactive FWA detection and monitoring via various techniques and tools including, but not limited to, data mining and analytics. (10%)
• Collaborate with DHMP departments and leadership to investigate allegations of FWA. (10%)
• Perform analysis of applicable regulations, contracts, and policy manuals to determine whether violations exist. (10%)
• Collect, analyze, and document evidence related to FWA investigations and/or projects to include, but not limited to: (10%)
• Conducting and documenting interviews of witnesses or subjects. (10%)
• Perform field work to include provider site visits and surveillance. (10%)
• Compile and organize accurate case file documentation and calculation of potential overpayments. (5%)
• Make referrals of case findings to appropriate law enforcement and/or regulators. Develop investigative summary reports documenting investigative activities and findings. (5%)
• Suggest program integrity measures and controls to enhance FWA prevention work. (5%)
• Serve as a resource for departments to research and resolve integrity inquiries and assist in identification of improvements to internal practices that may reduce or prevent FWA. (5%)
• Represent DHMP as a witness in court actions as required, and in affidavits as assigned. (5%)
• Support other team members within the Corporate Compliance Department, as assigned. (5%)
• Participate in preparing and submitting required reporting to regulatory agencies. (5%)
• Respond to data requests submitted by external authorized parties. (5%)

Education:

• Bachelor's Degree Required or
• High School Diploma or GED Required and
• Demonstrated experience. Required

Work Experience:

• 1-3 years At least two years of experience performing investigations or audits in the health care arena. Required

Licenses:

• CPC - Certified Professional Coder - AAPC - American Academy of Professional Coders Required

Knowledge, Skills and Abilities:

• Knowledge of medical terminology, healthcare claims, and medical coding.
• Demonstrated experience using data to perform investigations or audits, including intermediate skill level with Excel.
• Knowledge of Medicare and Medicaid requirements.
• Proficiency in Microsoft Office.

Shift

Work Type

Salary

Benefits

• Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to 9.5%, and generous medical plans

• Free RTD EcoPass (public transportation)

• On-site employee fitness center and wellness classes

• Childcare discount programs & exclusive perks on large brands, travel, and more

• Tuition reimbursement & assistance

• Education & development opportunities including career pathways and coaching

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program 

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

Our Values

• Respect

• Belonging

• Accountability

• Transparency

All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.
Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation.
As Colorado’s primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.
Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.
Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community.

Applicants will be considered until the position is filled.