SIU Field Investigator

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

• 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

• 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

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 14,000 employees, it is the largest private employer in the state, serving over 580,000 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.

USD $37.58/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.