Health Care Investigator

Now hiring a Health Care Investigator.

• Remote: Open to remote applicants in the United States, except for the following states: Wyoming, North Dakota, and Ohio

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, it's not just what we do that matters. It's 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.

• 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)

• 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
  
  

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
Presbyterian's 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 improve the health of patients, members, and the communities we serve. We are 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 state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

Inclusion and Diversity
Our culture is one of knowing and respecting our patients, members, and each other. We capture this in our Promise and CARES commitments.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

USD $34.27/Hr.

The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.