SIU Field Investigator
Share
Job Location:
Albuquerque, NM - USA
Monthly Salary:
Not Disclosed
Posted on:
20-10-2025
Vacancies:
1 Vacancy
Job Summary
Overview
Presbyterian is seeking a SIU Field Investigator
The Special Investigative Unit (SIU) Field Investigator supports Program Integrity Department initiatives at Presbyterian Health Plan. The SIU Field Investigator is responsible for conducting announced and unannounced provider onsite audits of medium to highly complexity related to suspected or actual healthcare fraud waste or abuse (FWA) 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; going onsite to the provider office and requesting and obtaining 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 FWA 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.
- This is a Full Time position - Exempt: Yes
- Job is based at Rev Hugh Cooper Admin Center
- Work hours: Days
Ideal Candidate: Bachelors Degree. Certified Professional Medical Auditor (CPMA) through the AAPC or Law Enforcement background
Qualifications
- Associates degree plus three (3) years related healthcare experience required. Three (3) 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 OR
- Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) If presenting with CFE or AHFI credential only must obtain CPC within 12 months of hire.
- Must reside in New Mexico
Responsibilities
- Medium to high complexity reviews/investigations involving provider issues
- Travel throughout the State of New Mexico to provider and/or facility offices required
- 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
Benefits
About Presbyterian Healthcare Services
Presbyterian offers a comprehensive benefits package to eligible employees including medical dental vision disability coverage life insurance and optional voluntary benefits.
The Employee Wellness Rewards Program encourages staff to engage in health-enhancing activities - like challenges webinars and screenings - with opportunities to earn gift to earn gift cards and other incentives.
As a mission-driven organization Presbyterian is deeply committed to improving community health across New Mexico through initiatives like growers markets and local partnerships. Founded in 1908 Presbyterian is a locally owned not-for-profit healthcare system with nine hospitals a statewide health plan and a growing multi-specialty medical group. With nearly 14000 employees it is the largest private employer in the state serving over 580000 health plan members through Medicare Advantage Medicaid and Commercial 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
Key Skills
- Epidemiology
- Public Health
- Bank Secrecy Act
- Bioinformatics
- Fraud
- Genetics
- Interviewing
- Law Enforcement
- Qualitative Research Interviewing
- Research Experience
- Next Generation Sequencing
- Writing Skills
About Company
Find the medical care and health plan you and your family need at Presbyterian Healthcare Services, an integrated system of hospitals, healthcare providers and insurance plans serving patients and members in New Mexico.
