Payment Integrity Investigator - Must Reside in ...

We are recruiting for a motivated Payment Integrity Investigator - Must Reside in Colorado to join our teamWe are here for life's journey.Where is your life journey taking you?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.DepartmentManaged 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 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. RequiredWork Experience:- 1-3 years At least two years of experience performing investigations or audits in the health care arena. RequiredLicenses: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.ShiftWork TypeRegularSalary$58,700.00 - $88,100.00 / yrBenefitsOur ValuesAll 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 or 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.[](

Created: 2026-01-16