Complex Interactions Specialist (Administrator III) - DORA: Division of Insurance

Colorado Department of Regulatory Agencies; Denver (CO); Hybrid; USD 85,000 - 110,000; Full time

Benefits offered by this job

RTD EcoPass

Flexible schedules

Wellness programs

Bike-to-work program

PERA retirement benefits

Medical and Dental Insurance

Job summary

The Colorado Department of Regulatory Agencies (DORA) seeks a Senior Medicare Fraud Investigator within the Senior Health unit to investigate consumer reports of Medicare fraud and coordinate with subgrantees and partner agencies. This role focuses on SMP programs, mentors staff, and supports data entry in the online reporting system.

Strong collaboration and attention to detail are essential. The position offers a hybrid work arrangement with some in-office reporting and flexible work options

Qualifications

• Six years of professional experience in healthcare or regulatory settings.
• Experience with fraud prevention and anti-fraud awareness.
• Experience with education and training on healthcare fraud prevention.
• Strong recordkeeping and information gathering skills.

Responsibilities

• Create protocols to manage investigations and ensure proper use of federal funds.
• Conduct partner trainings on entering fraud cases and interagency coordination.
• Design training content for local affiliates on fraud prevention.
• Serve as contact for subgrantees and ensure complete case submission.
• Maintain relationships with federal, state, and local partners on Medicare fraud investigations.

Skills

Health insurance inquiries

Fraud prevention

Training coordination

Recordkeeping

Education

Associate's Degree (related field)

Job description

Hybrid Workplace Arrangement:
Although this position will be designated under the department's hybrid workplace program, it will still be required to report to the department office on a scheduled basis and at the discretion of the supervisor, based on business needs.

This announcement may be used to fill multiple vacancies.

The Department of Regulatory Agencies (DORA) is dedicated to preserving the integrity of the marketplace and is committed to promoting a fair and competitive business environment in Colorado. Consumer protection is our mission.

DORA values and promotes diversity, supporting a workplace that is inclusive of people from different backgrounds and experiences; creating an environment that is reflective of our communities; promoting positive relationships; and putting forth unique perspectives to fulfill our mission.

• Employer-sponsored RTD EcoPass, with offices located at Civic Center Plaza, above the RTD Civic Center station and just a few blocks from RTD light rail.
• Extensive work-life programs such as flexible schedules, training and professional development opportunities on a wide variety of subjects, and more!
• Employee wellness programs, including the Colorado State Employee Assistance Program (CSEAP), which provides free, confidential counseling services.
• Bike-to-work programs, including access to storage lockers and bike racks.
• Flexible retirement benefits, including a choice of the PERA Defined Benefit Plan or the PERA Defined Contribution Plan, plus optional 401K and 457 plans.
• Medical and Dental Health Insurance for employees and optional coverage for their dependents.
• Life Insurance for employees, and optional coverage for their dependents.
• Paid Time Off, including 11 paid holidays.
• Short- and long-term disability coverage.
• Tuition assistance program.

Check out our excellent benefits package!

Description of Job

The Colorado Division of Insurance (DOI) regulates the insurance industry in Colorado. The DOI helps consumers by answering their questions, investigating their complaints, and helping them to understand their insurance. The DOI regulates and monitors the insurance companies in Colorado and insurance agents to ensure everyone follows the law.

The Senior Medicare Patrol (SMP) is a national program funded by the U.S. Department of Health and Human Services, Administration for Community Living (HHS/ACL) through a federal grant on an annual funding cycle beginning of June of each year. Under this grant, this work unit, the Colorado SMP program is tasked with providing Medicare fraud education and responding to fraud and abuse allegations reported directly by consumers or referred by agencies throughout the state. The outreach and education portion of the program is conducted primarily by fifteen (15) sub-grantee agencies consisting of Area Agencies on Aging, volunteer programs, community agencies, and non-profit organizations around the state which the Senior Health Unit at the Division of Insurance in DORA oversees. The complaint investigation function is centralized in the state, additionally, referrals for further investigation and enforcement are made to appropriate federal and/or state partners. As such, protection of vulnerable consumers is a core component of the SMP, as is eliciting the involvement of volunteers and other SMP team members at the local sub-grantee agencies to help educate beneficiaries and their caregivers on how to preve t, detect, and report Medicare fraud, abuse, and errors.

This position exists to investigate and assess consumer and other reports of suspected fraud, abuse, or error by Medicare healthcare providers or marketing agents and refer cases for federal or state enforcement actions as appropriate. This position focuses on SMP in the Senior Health (SHIP/SMP/MIPPA Programs) work unit. The position mentors and supports work done by the sub-grantee agency consisting of Area Agencies on Aging, volunteer programs, and community action agencies personnel, and volunteers in the identifications and reporting of suspected Medicare fraud; handles basic information gathering for cases, and refers more complex cases and questions. This position shares responsibility with the SMP Program Manager for managing database entries in the online reporting system to record suspected Medicare fraud and abuse.

Position

• SFA 64165

Duties Include, But Are Not Limited To

• Creating and managing protocols and systems to ensure timely and comprehensive management of investigations and cases based on consumer complaints in order to prevent and/or report inappropriate expenditure of federal funds for benefits, and maximize compliance by healthcare providers;
• Conducting conference calls with partners to hold refresher trainings on entering suspected fraud cases; joining conference calls and meetings with state and federal agencies and other investigative partners regarding case handling protocols and matters of interagency communication;
• Designing training content and setting standards for local affiliate personnel and volunteers to convey key preventive and remedial strategies to consumers; working with affiliate organizations around the state to provide high quality and timely consumer protection services including information and referral; educating federal and state agency partners regarding current trends and practices in prevention, detection, and prosecution of health care fraud in the Medicare program;
• Serving as a point of contact for receiving cases from subgrantees and ensuring submitted cases are complete from initial entry to closing;
• Cultivating and maintaining collaborative relationships with federal, state, and local agency partners involved in addressing health care fraud, including SMP Programs in other states; educating federal, state, and local agency partners regarding current trends and practices in prevention, detection, and prosecution of health care fraud in the Medicare program; providing expertise on laws, regulations, and activities related to Medicare fraud; initiating and maintaining communication for interagency coordination of fraud investigations and prosecutions; and coordinating referral of appropriate cases to federal and state enforcement agencies.

MINIMUM QUALIFICATIONS (MQs)

There are two ways to qualify for this position: 1) Experience OR 2) A Combination of Education and Experience

Option 1: Experience

• Six (6) years of professional* experience working for a healthcare provider, a non-profit health advocacy organization, in the health insurance industry, in a health policy consulting environment, or for a governmental regulatory entity which must include three (3) out of the four (4) of the following:
• Handling health insurance, Medicaid, and/or Medicare-related inquiries;
• Experience with fraud prevention and anti-fraud awareness;
• Coordinating and engaging in educational training about healthcare and/or healthcare fraud prevention; and/or
• Recordkeeping, information gathering, and/or document organization.

Option 2: A Combination of Education AND Experience

• Associate's Degree and Experience: Graduation from an accredited college or university with an associate's degree in business, communications, healthcare administration, healthcare management, public health, health economics, public administration, public policy, pr