Payment Integrity Investigator
Payment Integrity Investigator
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$ 58700 - 88100
1 Vacancy
Job Description
We are here for lifes journey.
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Being the heartbeat of Denver means our heart reflects something bigger than ourselves something that connects us all:
Humanity in action Triumph in hardship Transformation in health.
Department
Managed Care AdministrationJob SummaryUnder 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 Plans (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:
- Bachelors 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:
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
RegularSalary
$58700.00 - $88100.00 / yrBenefits
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 Denvers 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 Colorados 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 185000 individuals and 67000 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.
Employment Type
Full-Time
