What are the responsibilities and job description for the Provider Integrity Review Specialist position at State of Colorado Job Opportunities?
Department Information
STATE OF COLORADO RESIDENCY REQUIRED AT TIME OF APPLICATION
NOTE: This announcement may be used to fill multiple openings.
Envision yourself working at HCPF
The Department of Health Care Policy & Financing (HCPF) oversees and operates Health First Colorado (Colorado's Medicaid Program), Child Health Plan Plus (CHP ), and other state public health programs for qualified Coloradans. Our mission is to improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado.
We are committed to increasing the diversity of our staff and providing culturally responsive programs and services. Therefore, we encourage responses from people of diverse backgrounds and abilities.
We are looking for a Provider Integrity Review Specialist to join our Provider Integrity Section of Medicaid Operations Office!
As part of the State of Colorado, HCPF offers a competitive benefits package:
- PERA retirement benefits including PERA Defined Benefit Plan, PERA Defined Contribution Plan, plus 401K and 457 plans
- Medical, Dental, and Vision insurance coverage
- Automatic Short-Term and Optional Long-Term Disability Coverage
- Life and AD&D Insurance
- Flexible Spending Accounts (FSAs)
- Family Medical Leave Act (FMLA) job protection and State of Colorado Paid Family Medical Leave (PFML)
- 11 Paid Holidays Annually and Accrued Annual and Sick Leave
- Accrued Sick Leave for State of Colorado Temporary Employees
- Flexplace and Flextime work arrangements
- Variety of discounts on services and products available through the State of Colorado's Work-Life Employment Discount Program
- Free RTD EcoPass to all eligible State Employees
- Credit Union of Colorado Membership Eligibility
- Some positions may qualify for the Public Service Loan Forgiveness Program. For more
information, go to https://www.colorado.gov/pacific/dhr/student-loan-forgiveness-programs. https://dhr.colorado.gov/dhr-resources/student-loan-forgiveness-programs
We are onboarding new employees using a hybrid approach. The Department supports flexible work arrangements. Depending on the business need and description of the position, we have options that range from hybrid, to full-time in the office. Specific discussions about the schedule will be discussed during the offer stage.
Description of Job
The Fraud, Waste and Abuse (FWA) Division has the primary responsibility for detection and deterrence of provider fraud, waste and abuse, recovering overpayments, and performing preliminary investigations of potential fraud in the programs administered by the Department of Health Care Policy and Financing (Department), including the Colorado Medical Assistance Program (Medicaid) and the Colorado Children’s Basic Health Plan.
The Provider Integrity Section oversees investigation into Provider Fraud, Waste, and Abuse. They work within the unit to identify these areas and to collect overpayments, handle provider terminations, and assist in overall investigation. The unit also monitors program integrity functions of the Regional Accountable Entities with the Department’s managed care program.
This position exists to complete self audits, post-payment reviews, and fraud referrals as the Department receives referrals from both internal and external sources. If recoveries are made or if the Department receives a Self-Disclosure, this position is responsible for processing and ensuring that the federal financial participation is properly returned.
Duties include, but are not limited to:
Oversees the provider integrity functions of the Medicaid Program, including conducting post-payment reviews, self-audits, reviewing self-disclosures, and drafting fraud referralsReviews and drafts reports, letters, adverse action notices, requests for written responses, spreadsheets, newsletters, or any other items created within the job duty. Ensures that Department policy, state and federal rules, and medical coding principles are used accurately and are interpreted appropriately.
- Works with internal staff, including policy, rates, and data personnel, to coordinate, plan, and implement the necessary program integrity functions of the HCBS Waiver Program, including post-payment review of claims, obtaining claims datasets, and researching of HCBS rules and policies. Position utilizes expertise of reviewers of the Division, Department data and policy staff during development of audit projects, during informal reconsideration and formal appeals requested by the provider
- Reports provider integrity activities and progress to Department management as needed, including but not limited to review/investigation statuses, progress of illegal billing ticket resolutions, and statuses of letters and other correspondence issued to providers.
- Researches and gathers necessary information to make informed recommendations and compelling support to those recommendations to program staff and management to improve provider understanding and compliance with Medicaid rules
- Tracks, identifies, and notifies the supervisor of all audit review projects of individual provider and client billing patterns that appear to be fraudulent, or need more in-depth review than the scope of the contractor’s project. Develops a formal referral and referral workflow within the ICM with pertinent information for further review by the appropriate section/unit within the Division. Works with Department staff and law enforcement partners to obtain the necessary information required as part of the referral
- Conducts critical projects for the Division and Section. Researches information, analyzes data, proposes recommendations and solutions to management and Department staff in a timely and effective manner.
- Other duties as assigned
Minimum Qualifications, Substitutions, Conditions of Employment & Appeal Rights
H1G3XX
COMPLIANCE SPECIALIST III
Compliance Specialist class series description available online
Residency Requirement:
This posting is only open to residents of the State of Colorado at the time of submitting your application.
MINIMUM QUALIFICATIONS:
Experience Only:
Six (6) years of relevant experience in auditing, medical billing, healthcare regulation, public health, healthcare policy, Medicaid, CHIP, or public health administration.
OR
Education and Experience:
A bachelors degree from an accredited institution in Business, Healthcare Administration, Public Administration, Public Policy, Law, or other related field and two (2) years of professional experience in auditing, medical billing, healthcare regulation, public health, healthcare policy, Medicaid, CHIP, or public health administration.
Appropriate education will substitute for the required experience on a year-for-year basis. Relevant education will be calculated as the following:
- An associate will count as two years of experience
- A bachelors will count as four years of experience
- A masters degree will count for six years of experience
A doctorate or juris doctorate degree will count for seven years of experience
PREFERRED QUALIFICATIONS
- Prior state experience related to the duties of this position
- Masters degree in Public Health, Healthcare Administration, Healthcare Management, Social Work, Law or a related field
Experience in claims auditing
- Experience in medical billing
- Experience with payment processing
Experience with government healthcare programs
Experience with state and federal health care laws
Experience with designing and implementing compliance programs
DEFINITION OF PROFESSIONAL EXPERIENCE: Work that involves exercising discretion, analytical skill, judgment, personal accountability, and responsibility for creating, developing, integrating, applying, and sharing an organized body of knowledge that characteristically is uniquely acquired through an intense education or training regimen at a recognized college or university; equivalent to the curriculum requirements for a bachelor's or higher degree with major study in or pertinent to the specialized field; and continuously studied to explore, extend, and use additional discoveries, interpretations, and application and to improve data, materials, equipment, applications and methods.
Appeal Rights:
An applicant who has been removed from an employment list or removed from consideration during the selection process may request a review by the State Personnel Director.
As an applicant directly affected by the results of the selection or comparative analysis process, you may file a written appeal with the State Personnel Director.
Review of the completed, signed and submitted appeal will be timely on the basis of written
material submitted by you, using the official appeal form signed by you or your representative. This form must be completed and delivered to the State Personnel Board by email at dpa_state.personnelboard@state.co.us within ten (10) calendar days from your receipt of notice or acknowledgement of the Department’s action.
For further information on the Board Rules, you can refer to 4 Colorado Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, atspb.colorado.gov/board-rules.
Supplemental Information
How to Apply (PLEASE READ CAREFULLY)
Please note that ONLY your State of Colorado job application will be reviewed during the initial screening; if you submit a resume and cover letter, they will be reviewed in later stages of the selection process. Therefore, it is paramount that you clearly describe all your relevant experience on the application itself. Applications left blank or marked "SEE RESUME" will not be considered.
Your application will be reviewed against the minimum qualifications for the position. If your application demonstrates that you meet the minimum qualifications, you will be invited to the comparative analysis process, which is described below.
Comparative Analysis Process
The comparative analysis process will consist primarily of a review of applications against the minimum and preferred qualifications of this position. Applications will be reviewed in comparison to all others in the applicant pool in order to identify a top group of candidates who may be invited for a final interview. Depending on the size of the applicant pool, additional selection processes may be utilized to identify a top group of candidates. Applicants will be notified of their status via email.
Failure to submit properly completed documents by the closing date will result in your application being rejected.
ADAAA Accommodations: The State of Colorado believes that equity, diversity, and inclusion drive our success, and we encourage candidates from all identities, backgrounds, and abilities to apply. The State of Colorado is an equal opportunity employer committed to building inclusive, innovative work environments with employees who reflect our communities and enthusiastically serve them. Therefore, in all aspects of the employment process, we provide employment opportunities to all qualified applicants without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity or expression, pregnancy, medical condition related to pregnancy, creed, ancestry, national origin, marital status, genetic information, or military status (with preference given to military veterans), or any other protected status in accordance with applicable law.
The Department of Health Care Policy & Financing is committed to the full inclusion of all qualified individuals. As part of this commitment, our agency will assist individuals who have a disability with any reasonable accommodation requests related to employment, including completing the application process, interviewing, completing any pre-employment testing, participating in the employee selection process, and/or to perform essential job functions where the requested accommodation does not impose an undue hardship. If you have a disability and require reasonable accommodation to ensure you have a positive experience applying or interviewing for this position, please direct your inquiries to our ADAAA Coordinator, Virginia Miller, at virginia.miller@state.co.us.
The Department of Health Care Policy & Financing does not offer sponsored visas for employment purposes.
