Coder-Healthcare Fraud Investigator
Coder-Healthcare Fraud Investigator
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Job Description
Overview
Now hiring a Coder-Healthcare Fraud Investigator
The SIU Investigator III supports Program Integrity Department initiatives at Presbyterian Health Plan. The Special Investigative Unit (SIU) Investigator III is responsible for conducting medium to highly complex reviews into suspected or actual healthcare fraud waste or abuse with respect to provider pharmacy employee member and broker interactions involving the full range of products at Presbyterian. This includes the identification investigation prevention and reporting of fraudulent wasteful and/or abusive billing and/or coding practices and/or patterns; requesting and reviewing medical record documentation to determine if services billed were rendered and/or appropriate based on documentation; interviewing suspect(s) and/or witness(es) with knowledge of the suspect and/or actual fraud waste or abuse; coordination of recovery of overpayments related to fraudulent abusive and/or wasteful billing and/or coding practices; and providing education related to coding/representation of services and appropriate medical record documentation requirements. The ideal candidate should have proficient experience in healthcare claims fraud waste and abuse investigation with experience in government funded programs like Medicaid Medicare and the Marketplace along with Commercial health plans to include Federal Employee Health Benefits Plan and Self-Funded accounts.
How you belong matters here.
We value our employees differences and find strength in the diversity of our team and community.
At Presbyterian its not just what we do that matters. Its how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.
Why Join Us
- Full Time - Exempt: Yes
- Job is based Rev Hugh Cooper Admin Center
- Work hours: Days
- Benefits: We offer a wide range of benefits including medical wellness program vision dental paid time off retirement and more for FT employees.
Ideal Candidate:
- Bachelors degree and 5 years Healthcare Law Enforcement Background Ability to perform on site audits
Qualifications
- Bachelors degree plus three years related healthcare experience required. Six years of additional experience can be substituted in lieu of degree.
- Certified Professional Coder (CPC) through the American Academy of Professional Coders (AAPC) or equivalent required
- Preferred Qualifications
- Certified Professional Medical Auditor (CPMA) through the AAPC
- Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI)
Responsibilities
- Medium to high complexity reviews/investigations involving provider pharmacy employee member and broker issues
- Must be able to perform in-depth and complex medical coding audits in both an accurate and timely manner as part of the Special Investigative Units proactive effort as well as referral-based issues that are brought to the attention of the unit
- Strong and accurate technical and report writing skills are required as case management documentation reports and/or referrals to government agencies and legally binding documents are produced and handled by the SIU
- Maintain accurate current and detailed case information in the SIU case management system
- Strong verbal communication skills are required due to interface with government agencies providers and internal departmental collaboration
- Strong analytical skills necessary as this position will require interface with health plan claims system the vendor fraud analytics system the SIU case management system and other systems utilized by the SIU in investigating fraud waste and abuse allegations
- Ability to work independently to achieve Program Integrity Department and SIU objectives.
- Critical thinking and attention to detail
- Resolving conflict that arises from provider audit results and/or issues resulting from a fraud waste or abuse investigation
- Conduct research into coding rules and/or guidelines or other state or federal rules and/or laws depending on the nature of the suspect fraud waste or abuse
- Maintains caseload and manages daily case review assignments and productivity standards with attention and accountability towards achieving a quality product
- Monitor cases post-audit to determine if continued aberrancies exist that require additional follow-up and review
Intermediate level of: - Ensures adherence to state and federal laws and regulations managed care awareness along with reimbursement and coding policies and guidelines to include internal Presbyterian Health Plan enterprise operations functions and processes
Intermediate level using: - MS Office (Word Excel PowerPoint)
- Adobe Pro
- Internet
- Microsoft Teams and/or Zoom
- In collaboration with SIU Manager and Senior Investigator manages the overall direction coordination implementation execution and completion of assigned investigations ensuring consistency with department strategy commitments and goals
- Responsible for concurrent and/or retrospective review data abstraction analysis identification of critical issues process improvement support required education and assisting with measurement of performance metrics
- Serves as resource recommending process modifications and practice changes to improve efficiency effectiveness and reliability of processes and systems
- Builds and develops collaborative relationships vital to the success of cases and department
- Conducts advanced fraud waste and abuse audits in accordance with compliance and audit work-plan and prepares detailed audit reports for management legal counsel and providers
- Identifies investigates and resolves billing and coding related inquiries and complaints from beneficiaries members regulatory agencies and internal and external customers through recoupment of overpayments and education to providers
Benefits
All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical dental vision short-term and long-term disability group term life insurance and other optional voluntary benefits.
Wellness
Presbyterians Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges webinar preventive screening and more.
Why work at Presbyterian
As an organization we are committed to improving the health of our communities. From hosting growers markets to partnering with local communities Presbyterian is taking active steps to improve the health of New Mexicans.
About Presbyterian Healthcare Services
Presbyterian exists to ensure the patients members and communities we serve can achieve their best health. We are a locally owned not-for-profit healthcare system of nine hospitals a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908 we are the states largest private employer with nearly 14000 employees.
Our health plan serves more than 580000 members statewide and offers Medicare Advantage Medicaid (Centennial Care) and Commercial health plans.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
Maximum Offer for this position is up to
Compensation Disclaimer
Employment Type
Full-Time
