Under minimal supervision supports the continuous evaluation of the Department in alignment with Denver Health's financial, strategic, and operational initiatives and projects. Evaluates business processes, anticipates opportunities and challenges, identifies areas for improvement and makes data-driven recommendations. Coordinates and performs duties related to data acquisition and analysis for multiple projects simultaneously.
This position is responsible for the prospective and retrospective investigation of suspect claims and the development of fraud, waste, abuse and overpayment recovery cases. This includes independently gathering, analyzing and interpreting complex data and information to provide meaningful results in developing leads, collaboration with internal resources as well as complying with state and federal requirements for fraud, waste and abuse detection and prevention. Additionally this role assists in the training of new associates and in education to business areas to be on the alert for suspect claims or potentially fraudulent activity.
*Gather and prepare reporting as assigned for internal use. Analyze and triage referrals/leads and determine what type of research/investigation is needed.
*Plan, direct and coordinate investigations and evaluate moderate to complex potential fraud, waste, or abuse, including pre-pay and/or post-pay medical claims reviews to determine valid cases for appropriate action.
*Documents findings, and prepares case referrals, letters, and reports.
*Conduct interviews of patients, providers, provider staff and other witness/experts.
*Represent Denver Health Medical Plan by testifying at trials, offering depositions and responding to subpoenas.
*Prepare for and facilitate settlement negotiations with providers, attorneys and other responsible parties.
*Independently, accurately and completely documents case activity and conducts follow-up actions in a timely manner.
*Refer well documented and substantiated cases to law enforcement agencies which may include the Federal Bureau of Investigations (FBI), the Office of the Attorney General (OIG) and local police departments.
*Meet all contractual, State and Federal regulations and reporting requirements as established by CMS, FEP/OPM, HCPF and other agencies.
*Use strong knowledge of analysis and investigation skills to develop and identify recovery opportunities and collect overpayments.
*Identify education opportunities; and deliver education and training to team members; and assists in the development and presentation of anti-fraud training to various divisions/departments of the organization.
*Develop and expand your knowledge of FWA trends and schemes to efficiently intake and evaluate reports of FWA received by the department.
*Other duties as assigned.
1. Two (2) years in data analysis, process improvement, or project management required.
2 .Experience in health insurance preferred.
Knowledge, Skills and Abilities
1. Must be able to work independently and meet schedules and deadlines. Ability to handle multiple tasks, simultaneously.
2. Exceptional ability to gather, understand, and utilize data to inform decisions and make recommendations. Excellent communication skills and ability to summarize detailed information in an organized, concise manner.
3. Strong analytical and problem-solving skills and ability to compile, categorize, calculate, audit, and/or verify data.
4. Project management skills, including the ability to manage several projects simultaneously while remaining flexible with changing priorities. Strong ability and comfort in presenting data, recommendations, and proposals to a wide variety of audiences and levels of leadership (both written and verbally).
Computers and Technology
1. Intermediate proficiency with Microsoft Office, specifically Excel required
2. Knowledge of relational databases (Microsoft SQL Server) and proficiency in SQL preferred
Knowledge, Skills and Abilities
1. Knowledge of applicable fraud statutes and regulations, and of federal guidelines on recoupments and other anti-FWA activity
2. Knowledge of claims processing, billing, reimbursement, or provider contracting.
3. Knowledge of HIPAA, data privacy, and/or data security processes.
4. Ability to work with regulators governing (public or private) health insurance carriers.
5. Knowledge of Medicare, Medicaid, and commercial fee-for-service schedules, and industry regulations issued by the Center of Medicare and Medicaid Services ("CMS") and the Colorado Department of Health Care, Policy & Financing ("HCPF") and the Colorado Division of Insurance.
6. Knowledge of all claims forms and coding types, including UB-04, CMS 1500, ICD-10, HCPC, Revenue Codes and NDC coding,HIPPA, HEDIS, NCQA.
7. Outstanding written and oral communication skills required.
8. Exceptional demonstrated written and oral communication, interpersonal and negotiation skills to communicate with management, regulators and law enforcement.
9. Proven analytic, writing and reasoning skills, including the ability to evaluate complaints, referrals and health care data laws and regulations and relevant federal laws and regulations, including but not limited to HIPAA.
10. Excellent organizational skills and the ability to manage and prioritize multiple investigations, projects and responsibilities while guiding other investigators.
11. Demonstrated knowledge of health care nomenclature and coding, programs, services, claims and fraud, waste and abuse schemes.
12. Highly organized with a high level of attention to detail
13. Ability to solve complex problems and willing to consider multiple possible solutions or causes.
Computers and Technology
1.MS Office required
1. Bachelor's Degree required. Concentration in business administration, finance, health care, or economics preferred.
Location Denver Health Medical Plan
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, efficient, high-quality academic health care system that is considered a model for the nation. The Denver Health system includes the Rocky Mountain Regional Level I Trauma Center, a 525-bed acute care medical center, Denver's 911 emergency medical response system, 8 family health centers, 15 school-based health centers, the Rocky Mountain Poison and Drug Center, the Denver Public Health Department, an HMO, and The Denver Health Foundation.
As Colorado's primary safety net institution, Denver Health is a mission-driven organization that has provided more than $3.3 billion in care for the uninsured in the last ten years. Denver Health is a leader in performance and quality improvements and remains financially secure, in part, due to its nationally recognized implementation of lean principles in healthcare. Denver Health is a major resource to the community, serving approximately 185,000 individuals and 67,000 children a year.
Located just south of downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.
We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE).
"Denver Health is committed to provide equal treatment and equal employment opportunities to all applicants and employees. Denver Health is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class."
Internal Number: 3637
About Denver Health
Take your career to the next level at Denver Health, where we offer a robust benefits package and endless opportunities for growth. Denver Health is a nationally-ranked, locally-trusted, premier healthcare institution located in the heart of Denver, Colorado.Twenty-five percent of all Denver residents, or approximately 150,000 individuals, receive their health care here. We are known as an integrated health care system that encompasses multidisciplinary academic specialties, a community health system, a level I adult trauma center, pediatric emergency and urgent care center home to Denver Public Health and many of the nation’s leaders in medicine.