Presbyterian Healthcare Services
Coder-Healthcare Fraud Investigator
Presbyterian Healthcare Services, Albuquerque, New Mexico, United States, 87101
Presbyterian Healthcare Services is seeking a talented Coder-Healthcare Fraud Investigator. The SIU Investigator III supports Program Integrity efforts by conducting complex investigations into suspected healthcare fraud, waste, or abuse across providers, pharmacies, employees, members, and brokers.
Overview
Responsibilities include reviewing medical records, identifying improper billing or coding practices, interviewing involved parties, coordinating overpayment recovery, and educating on documentation standards. Ideal candidates bring strong experience in healthcare claims investigations, especially within Medicaid, Medicare, Marketplace, and commercial health plans. Job Details
This is a Full Time position - Exempt: Yes Remote: Open to remote applicants in the United States, except for the following states: California, Illinois, North Dakota, New York, Ohio, Washington and Wyoming Work hours: Days Ideal Candidate
The ideal candidate has extensive experience investigating healthcare claims fraud, waste, and abuse—particularly within Medicaid, Medicare, Marketplace, and commercial plans—and is skilled in medical record review, billing analysis, and stakeholder interviews. Qualifications
Bachelor's 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
Conduct complex investigations involving providers, pharmacies, employees, members, and brokers. Perform detailed medical coding audits and analyze referral-based fraud, waste, or abuse cases. Prepare accurate reports, legal documents, and referrals for government agencies. Maintain thorough case documentation in the SIU case management system. Communicate effectively with government agencies, providers, and internal teams. Use multiple systems to analyze claims and detect fraudulent patterns. Research coding rules and regulations to support investigations. Resolve conflicts from audit findings and manage post-audit case reviews. Collaborate on investigations and recommend process improvements. Conduct audits, recover overpayments, and educate providers on billing practices. Benefits
Presbyterian offers a comprehensive benefits package to eligible employees, including medical, dental, vision, disability coverage, life insurance, and optional voluntary benefits. About Presbyterian Healthcare Services
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.
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Responsibilities include reviewing medical records, identifying improper billing or coding practices, interviewing involved parties, coordinating overpayment recovery, and educating on documentation standards. Ideal candidates bring strong experience in healthcare claims investigations, especially within Medicaid, Medicare, Marketplace, and commercial health plans. Job Details
This is a Full Time position - Exempt: Yes Remote: Open to remote applicants in the United States, except for the following states: California, Illinois, North Dakota, New York, Ohio, Washington and Wyoming Work hours: Days Ideal Candidate
The ideal candidate has extensive experience investigating healthcare claims fraud, waste, and abuse—particularly within Medicaid, Medicare, Marketplace, and commercial plans—and is skilled in medical record review, billing analysis, and stakeholder interviews. Qualifications
Bachelor's 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
Conduct complex investigations involving providers, pharmacies, employees, members, and brokers. Perform detailed medical coding audits and analyze referral-based fraud, waste, or abuse cases. Prepare accurate reports, legal documents, and referrals for government agencies. Maintain thorough case documentation in the SIU case management system. Communicate effectively with government agencies, providers, and internal teams. Use multiple systems to analyze claims and detect fraudulent patterns. Research coding rules and regulations to support investigations. Resolve conflicts from audit findings and manage post-audit case reviews. Collaborate on investigations and recommend process improvements. Conduct audits, recover overpayments, and educate providers on billing practices. Benefits
Presbyterian offers a comprehensive benefits package to eligible employees, including medical, dental, vision, disability coverage, life insurance, and optional voluntary benefits. About Presbyterian Healthcare Services
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.
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