"Alerted.org

Fraud Waste and Abuse Division Director

Print (https://www.governmentjobs.com/careers/colorado/jobs/newprint/4941547)

Apply



Fraud Waste and Abuse Division Director

Salary

$103,644.00 - $165,840.00 Annually

Location

Denver Metro, CO

Job Type

Full Time

Job Number

UHA01380 03/08/2025

Department

Department of Health Care Policy and Financing

Division

Medicaid Operations Office

Opening Date

05/14/2025

Closing Date

5/29/2025 11:59 PM Mountain

FLSA

Determined by Position

Primary Physical Work Address

303 E. 17th Avenue, Denver CO 80203

FLSA Status

Exempt; position is not eligible for overtime compensation.

Department Contact Information

[email protected]

Type of Announcement

A residency waiver has been granted for this announcement. Applications will be considered from residents and non-residents of Colorado.

How To Apply

Please submit an online application for this position at https://www.governmentjobs.com/careers/colorado. Reach out to the Department Contact to apply using a paper application, including any supplemental questions. Failure to submit a complete and timely application may result in the rejection of your application. Applicants are responsible for ensuring that application materials are received by the appropriate Human Resources office before the closing date and time listed.

+ Description

+ Benefits

+ Questions

Department Information

A residency waiver has been granted for this announcement. Applications will be considered from residents and non-residents of Colorado.

NOTE: This announcement may be used to fill multiple openings.

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.

As part of the State of Colorado, HCPF offers a competitive benefits package: (https://dhr.colorado.gov/state-employees/state-of-colorado-employee-benefits)

+ PERA retirement benefits including PERA Defined Benefit Plan, PERA Defined Contribution Plan, plus 401K and 457 plans

+ Medical (https://dhr.colorado.gov/state-employees/state-employee-benefits/medical-benefits) , Dental (https://dhr.colorado.gov/state-employees/state-employee-benefits/dental-insurance) , and Vision (https://dhr.colorado.gov/state-employees/state-employee-benefits/vision-insurance) insurance coverage

+ Automatic Short-Term and Optional Long-Term Disability Coverage (https://dhr.colorado.gov/state-employees/state-employee-benefits/disability-insurance)

+ Life and AD&D Insurance

+ Flexible Spending Accounts (https://dhr.colorado.gov/state-employees/state-employee-benefits/flexible-spending-accounts) (FSAs)

+ Family Medical Leave Act (FMLA) (https://dhr.colorado.gov/state-employees/time-off-leave/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 (https://dhr.colorado.gov/state-employees/time-off-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 (https://www.rtd-denver.com/fares-passes/ecopass) to all eligible State Employees

+ Credit Union of Colorado (https://www.cuofco.org/credit-union-colorado-membership-eligibility) 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

Fraud, Waste and Abuse Division

The FWA Division has the primary responsibility for detection and deterrence of provider fraud, waste and abuse (FWA), 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, or Child Health Plan Plus (CHP+).

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 Medicaid Operations Office welcomes your interest in the Fraud Waste and Abuse (FWA) Division Director position. The position manages and oversees the daily operation of the FWA Division, each of its sections and units, and the Deputy Director position. This includes developing, implementing, and monitoring business plans, budgets and long-term strategy plans needed to carry out Division and Department goals and missions. This position monitors staffing and resourcing levels to ensure work can be adequately completed and in a timely manner by all staff within the Division.

Additional responsibilities in this position include:

+ Provide expertise, critical thinking and guidance to staff, management and other Department areas on sensitive and complicated program integrity concerns, oversight and referrals.

+ Oversee and direct all activities and functions occurring under the FWA Division and implement policies and guidelines.

+ Establish and maintain working relationships with outside agencies such as the State Attorney General’s Office, Medicaid Fraud Control Unit (MFCU), Department of Law, Board of Medical Examiners (BME), Regulatory Agencies, Office of the Inspector General (OIG), the Centers for Medicare and Medicaid (CMS), U.S. Attorney’s Office, United States Department of Justice, and the Federal Bureau of Investigation (FBI).

+ Primary liaison on all provider review cases.

+ Primary liaison with the Department’s fiscal agent for provider representative issues involving potential fraud.

+ Primary liaison to vendors conducting work on behalf of FWA.

+ Determine workload assignments and coordinate referrals.

+ Represent the Department in Administrative Hearings and criminal proceedings.

+ Oversee recovery actions, provide final sign-off for all provider sanction letters and collaborate with section managers and executive staff in negotiation of provider settlements.

+ Sign off on all formal referrals to the MFCU and the State Attorney General’s Office.

+ Accountable, including signature authority, for actions and decisions that directly impact pay, status, and tenure of the full-time equivalent positions within the FWA Division.

Minimum Qualifications, Substitutions, Conditions of Employment & Appeal Rights

Residency Requirement:

This posting is open to current and non-current residents of the State of Colorado at the time of submitting your application. However, if you are selected and accept the position, you will be required to establish residence in the State of Colorado.

Class Code & Classification Description:

H1A4XX PROGRAM MANAGEMENT III (https://drive.google.com/file/d/0B4enHpLSVk4eQjFoWE10NVJSX1U/view?resourcekey=0-VJYWFDAOXlezd5Kua\_eqQA)

MINIMUM QUALIFICATIONS:

Experience Only:

Experience Only:

Ten (10) years of relevant experience in overseeing Medicaid or Medicare fraud, waste, and abuse (FWA) operations that includes work on:

+ Program Integrity

+ Provider Payment Reviews

+ Fraud Investigation

+ Waste and abuse reviews and recoveries

+ Recovery Audit Contract (RAC)

+ Data analytics and data mining for FWA activities

+ State legislative processes, hospital associations, advocacy groups, oversight boards

OR

Education and Experience:

A combination of related education and/or relevant experience in an occupation

related to healthcare fraud, waste, and abuse (FWA) operations that is equal to ten (10) years that includes work on:

+ Program Integrity

+ Provider Payment Reviews

+ Fraud Investigation

+ Waste and abuse reviews and recoveries

+ Recovery Audit Contract (RAC)

+ Data analytics and data mining for FWA activities

+ Legislative processes, hospital associations, advocacy groups, oversight boards

Preferred Qualifications

+ Professional experience in managing multiple work units and groups, specifically focusing on program integrity, provider payment reviews, fraud investigations, waste and abuse reviews and recoveries, RAC, FWA data analytics, and compliance monitoring activities. This includes monitoring staffing and resource levels to ensure work is being performed adequately and timely. This also includes developing, implementing, and monitoring business plans and budgets.

+ Professional experience working directly with various law enforcement agencies and partners regarding potential FWA cases and ongoing investigations. This also includes experience supporting a State Attorney General’s Office in handling formal appeal cases.

+ Professional experience handling FWA cases, including overseeing preliminary investigations and referrals to law enforcement agencies.

+ Professional experience identifying and recovering waste and abuse from provider billing for Medicaid and/or Medicare services. This also includes education for providers on proper and appropriate billing practices.

+ Professional experience with handling administrative and criminal legal cases, including participating in settlement conferences, reviewing and approving legal documents, reviewing and negotiating settlement agreements, and participating in legal proceedings, including testifying on the behalf of a Medicaid agency.

+ Professional experience with creating and implementing policies and procedures for business processes in a professional work environment, as well as developing policies and procedures that improve program integrity compliance within a Medicaid agency.

+ Professional experience overseeing data analytics and data mining activities to help identify targeted opportunities for reducing FWA among Medicaid providers.

+ Professional experience managing contingency-based contracts.

+ Professional experience working collaboratively with officials from the Centers for Medicare and Medicaid Services (CMS) on FWA regulations, policies, and best practices.

+ Experience working with state lawmakers and policy makers to develop, respond to, and shape state legislation related to FWA activities.

+ Experience working with provider associations, advocacy groups, and oversight boards related to FWA activities.

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.

CONDITIONS OF EMPLOYMENT:

+ All positions at HCPF are security sensitive positions and require that the individuals undergo a criminal record background check as a condition of employment.

+ Employees who have been disciplinary terminated, resigned in lieu of disciplinary termination, or negotiated their termination from the State of Colorado must disclose this information on the application.

+ Travel:In-state travel with potential overnight duration is necessary. In addition, out-of-state travel for training or conferences pertaining to Program Integrity function and contract management is possible.

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 [email protected] 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, at spb.colorado.gov/board-rules .

Supplemental Information

How to Apply (https://careers.colorado.gov/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 [email protected] .

The Department of Health Care Policy & Financing does not offer sponsored visas for employment purposes.

The State of Colorado offers permanent employees a variety of benefits including medical, dental, life and disability insurance, as well as a comprehensive leave program. Please click the following link for detailed information: www.colorado.gov/pacific/dhr/benefits

Please note that each agency's contact information is different; therefore, we encourage all applicants to view the full, official job announcement which includes contact information and class title. Select the job you wish to view, then click on the "Print" icon.

01

All HCPF positions are security-sensitive positions and require potential employees to undergo a criminal record background check. As a condition of employment, you will be required to submit to pre-employment screening if offered the position. Are you willing to meet this requirement?

+ Yes

+ No

02

Do you have any relatives or significant others working at the Department of Health Care Policy & Financing? If so, please list their names here. Otherwise, please list N/A.

03

Are you willing to accept an offer within the posted salary range?

+ Yes

+ No

04

Former state employees who were disciplinarily terminated or resigned in lieu of termination must disclose the information on the application. In the space below, please provide an explanation as to why the prior termination or resignation should NOT disqualify your application from the current position. Otherwise, please list N/A.

05

List any additional relevant experience you would like us to consider in determining if you meet the qualifications of this position. Please, include the months and years relevant to the experience you describe.

06

As appropriate, please explain how your professional experience addresses the preferred qualifications of having the ability to come up with unusual or clever ideas about a given topic or situation.

07

Per the requirements of the Step Pay Program implemented on July 1, 2024, any State employee must be paid a rate that is equal to or greater than the appropriate step pay rate within their classification’s pay range based on completed years in their current class series as of June 30. All current and former State employees must ensure that your entire work history within the State Classified System, including at Institutions of Higher Education, is indicated in your application so that your time-in-series can be calculated accurately. Please verify that this information is included in your application in the supplemental questions.

08

Please define and describe your Medicaid, Medicare, and/or private insurance waste and abuse prevention and recoveries accomplishments. What experience do you have identifying waste and abuse with specific provider types (e.g., hospitals, durable medical equipment, home and community based services, non-emergency transportation, etc.)

09

Please describe your experience overseeing a diverse staff working across multiple areas of FWA, such as program integrity, RAC, and fraud investigations. How did you ensure cohesion and collaboration across these different teams to support a coordinated FWA approach for Medicaid?

10

Please describe how you have interacted with attorneys and other staff in a State Attorney General’s Office (AGO) on FWA cases. What was your role vis-a-vis their role? How did you support staff in working with the AGO staff?

11

Please describe your experience working with FWA vendors, for example, RAC vendors. What kind of contractor oversight have you done with vendors working in FWA?

12

Please detail your experience dealing with legislators, hospital associations, advocacy groups, and oversight boards related to FWA activities.

Required Question

Employer

State of Colorado

Address

See the full announcement by clicking

the "Printer" icon located above the job title

Location varies by announcement, Colorado, --

Website

https://careers.colorado.gov/

Apply

Please verify your email addressVerify Email