Program Integrity Review Specialist Print (https://www.governmentjobs.com/careers/colorado/jobs/newprint/5027462) Apply  Program Integrity Review Specialist Salary $50,856.00 - $66,120.00 Annually Location Denver Metro, CO Job Type Full Time Job Number UHA04841_07.2025 Department Department of Health Care Policy and Financing Division Medicaid Operations Office Opening Date 08/05/2025 Closing Date 8/13/2025 11:59 PM Mountain FLSA Determined by Position Type of Announcement This position is open only to Colorado state residents. Primary Physical Work Address 303 E 17th Ave Denver, CO 80203 FLSA Status Non-Exempt; position is eligible for overtime compensation. Department Contact Information Jessica Boyer, Talent Acquisition Specialist ~ jessica.boyer@state.co.us 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 STATE OF COLORADO RESIDENCY REQUIRED AT TIME OF APPLICATION NOTE: This announcement may be used to fill multiple openings. The State of Colorado strives to create a Colorado for All by building and maintaining workplaces that value and respect all Coloradans through a commitment to equal opportunity and hiring based on merit and fitness. The State is resolute in non-discriminatory practices in everything we do, including hiring, employment, and advancement opportunities. 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 looking for a Program Integrity Review Specialist to join our Program Integrity, Personnel & Operations Section team! 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 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 This position exists to conduct and monitor the program integrity functions and activities of the Medicaid Program, specifically pre-payment claims review activities occurring within the FWA Division. Typical duties (under supervision) include, but are not limited to: + Overseeing the program integrity functions of the Medicaid Program, including conducting and participating in provider pre-payment claims reviews and investigations, coordinates review projects and audit schedules and resolving provider billing issues as they arise + Working with internal staff, including policy, rates, and data personnel, to coordinate, plan, and implement the necessary program integrity functions of the Medicaid Program. Conducting research of rules and regulations as needed, including utilizing expertise of reviewers of the Division, Department program and policy staff and Department data analysts + Reviewing and drafting reports, letters, adverse action notices, spreadsheets, newsletters, or any other items created within the job duty. Ensuring that Department policy, state and federal rules, and medical coding principles are used accurately and are interpreted appropriately + Reporting program integrity activities and progress to Department management as needed, including but not limited to reviewing and investigating progress and statuses of letters and other correspondence issued to providers and overpayment, pre-payment claims denials, recovery and financial details + Researching and gathering 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 + Designing and maintaining electronic tracking spreadsheets/databases for tracking all the audit plans, audit project progress, project work products, identified pre-payment claims denials, overpayments, requested informal reconsiderations, formal appeals, and hearing preparation. Adding and maintaining information and data housed in the Division case management applications + Tracking, identifying, and notifying the Section Manager 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. Developing a formal referral and referral workflow within the ICM with pertinent information for further review by the appropriate section/unit within the Division. Working with Department staff and law enforcement partners to obtain the necessary information required as part of the referral + Conducting critical projects for the Division and Section. Researching information, analyzing data, proposing recommendations and solutions to management and Department staff + Other duties as assigned Minimum Qualifications, Substitutions, Conditions of Employment & Appeal Rights H1G2XXCOMPLIANCE SPECIALIST II Compliance Specialist class series description available online (https://drive.google.com/file/d/0BwUD9Bt4G-21Z2JqZ1NxMnFJOWM/view?usp=sharing&resourcekey=0-sDX7OHDb07CtXUL5Rxdq7g) 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: Five (5) years of professional Medicaid experience in the area of fraud, waste, and abuse. OR Education and Experience: A bachelor's degree from an accredited institution in a related field and one (1) year of professional Medicaid experience in the area of fraud, waste, and abuse. Appropriate education will substitute for the required experience on a year-for-year basis.Relevanteducation 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 or current state experience related to the duties of this position + Experience in compliance work specifically related to fraud, waste and abuse + Experience reviewing provider claim data + Experience working within the Medicaid Management Information System (MMIS) + One or more years of professional experience analyzing claims data for billing accuracy + One or more years of professional experience collaborating with policy staff and management on billing rules 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. + In-state travel with potential overnight duration is necessary. In addition, out of state travel for training or conferences pertaining to program integrity functions 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 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, 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, Minnie Kaur, at anupreet.kaur@state.co.us . 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 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. + Yes + No 04 Are you willing to accept an offer within the posted salary range? + Yes + No 05 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. 06 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. 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