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Denver Health Business Analyst - Fraud, Waste and Abuse (Managed Care Admini in Denver, Colorado

Business Analyst - Fraud, Waste and Abuse (Managed Care Administration)(Job ID: 3637)Job SummaryUnder minimal supervision supports the continuous evaluation of the Departmentin alignment with Denver Health's financial, strategic, and operationalinitiatives and projects. Evaluates business processes, anticipatesopportunities and challenges, identifies areas for improvement and makesdata-driven recommendations. Coordinates and performs duties related to dataacquisition and analysis for multiple projects simultaneously.This position is responsible for the prospective and retrospectiveinvestigation of suspect claims and the development of fraud, waste, abuseand overpayment recovery cases. This includes independently gathering,analyzing and interpreting complex data and information to provide meaningfulresults in developing leads, collaboration with internal resources as wellas complying with state and federal requirements for fraud, waste and abusedetection and prevention. Additionally this role assists in the training ofnew associates and in education to business areas to be on the alert forsuspect claims or potentially fraudulent activity.Responsibilities*Gather and prepare reporting as assigned for internal use. Analyze and triagereferrals/leads and determine what type of research/investigation is needed.*Plan, direct and coordinate investigations and evaluate moderate to complexpotential fraud, waste, or abuse, including pre-pay and/or post-paymedical 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 otherwitness/experts.*Represent Denver Health Medical Plan by testifying at trials, offeringdepositions and responding to subpoenas.*Prepare for and facilitate settlement negotiations with providers,attorneys and other responsible parties.*Independently, accurately and completely documents case activity andconducts follow-up actions in a timely manner.*Refer well documented and substantiated cases to law enforcement agencieswhich may include the Federal Bureau of Investigations (FBI), the Officeof the Attorney General (OIG) and local police departments.*Meet all contractual, State and Federal regulations and reportingrequirements as established by CMS, FEP/OPM, HCPF and other agencies.*Use strong knowledge of analysis and investigation skills to develop andidentify recovery opportunities and collect overpayments.*Identify education opportunities; and deliver education and training toteam members; and assists in the development and presentation of anti-fraudtraining to various divisions/departments of the organization.*Develop and expand your knowledge of FWA trends and schemes to efficientlyintake and evaluate reports of FWA received by the department.*Other duties as assigned.Experience1.Two (2) years in data analysis, process improvement, or projectmanagement required.2 .Experience in health insurance preferred.Knowledge, Skills and Abilities1.Must be able to work independently and meet schedules and deadlines. Abilityto handle multiple tasks, simultaneously.2.Exceptional ability to gather, understand, and utilize data to informdecisions and make recommendations. Excellent communication skills and abilityto 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 severalprojects simultaneously while remaining flexible with changing priorities.Strong ability and comfort in presenting data, recommendations, andproposals to a wide variety of audiences and levels of leadership (bothwritten and verbally).Computers and Technology1.Intermediate proficiency with Microsoft Office, specifically Excel required2.Knowledge of relational databases (Microsoft SQL Server) and proficiencyin SQL preferredKnowledge, Ski

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