SIU Field Investigator

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Summary:

Responsibilities:

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.

Some key responsibilities include:

• 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

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

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.

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