Presbyterian Healthcare Services
SIU Field Investigator
Presbyterian Healthcare Services, Albuquerque, New Mexico, United States, 87101
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 high 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 suspects and/or witnesses; 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, including Federal Employee Health Benefits Plan, and Self-Funded accounts. Base pay
Base pay range: $24.62/hr - $37.58/hr This range is provided by Presbyterian Healthcare Services . Your actual pay will be based on your skills and experience — talk with your recruiter to learn more. Responsibilities
Medium to high complexity reviews/investigations involving provider issues Travel throughout the State of New Mexico to provider and/or facility offices required Perform in-depth and complex medical coding audits in both accurate and timely manner as part of the SIU proactive effort, as well as referral-based issues Strong and accurate technical and report writing skills; 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 due to interface with government agencies, providers, and internal departments Strong analytical skills when interfacing with health plan claims system, vendor fraud analytics system, SIU case management system, and other systems used by the SIU Work independently to achieve Program Integrity Department and SIU objectives Critical thinking and attention to detail Resolve conflicts arising from provider audit results or fraud, waste, or abuse investigations Research coding rules and guidelines and state or federal rules as applicable Maintain caseload and manage daily case review assignments and productivity with focus on quality Monitor cases post-audit for continued aberrancies requiring follow-up 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 credentialed only, CPC must be obtained within 12 months of hire Must reside in New Mexico Ideal Candidate
Bachelor’s Degree. Certified Professional Medical Auditor (CPMA) through the AAPC or Law Enforcement background. Employment details
This is a Full Time position - Exempt: Yes Job is based at Rev Hugh Cooper Admin Center Work hours: Days Benefits
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 with opportunities to earn gift cards and other incentives. Presbyterian is a mission-driven, not-for-profit organization serving New Mexico with nine hospitals, a statewide health plan, and a growing multi-specialty medical group. 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 USD $37.58/Hr. Compensation Disclaimer 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.
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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 high 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 suspects and/or witnesses; 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, including Federal Employee Health Benefits Plan, and Self-Funded accounts. Base pay
Base pay range: $24.62/hr - $37.58/hr This range is provided by Presbyterian Healthcare Services . Your actual pay will be based on your skills and experience — talk with your recruiter to learn more. Responsibilities
Medium to high complexity reviews/investigations involving provider issues Travel throughout the State of New Mexico to provider and/or facility offices required Perform in-depth and complex medical coding audits in both accurate and timely manner as part of the SIU proactive effort, as well as referral-based issues Strong and accurate technical and report writing skills; 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 due to interface with government agencies, providers, and internal departments Strong analytical skills when interfacing with health plan claims system, vendor fraud analytics system, SIU case management system, and other systems used by the SIU Work independently to achieve Program Integrity Department and SIU objectives Critical thinking and attention to detail Resolve conflicts arising from provider audit results or fraud, waste, or abuse investigations Research coding rules and guidelines and state or federal rules as applicable Maintain caseload and manage daily case review assignments and productivity with focus on quality Monitor cases post-audit for continued aberrancies requiring follow-up 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 credentialed only, CPC must be obtained within 12 months of hire Must reside in New Mexico Ideal Candidate
Bachelor’s Degree. Certified Professional Medical Auditor (CPMA) through the AAPC or Law Enforcement background. Employment details
This is a Full Time position - Exempt: Yes Job is based at Rev Hugh Cooper Admin Center Work hours: Days Benefits
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 with opportunities to earn gift cards and other incentives. Presbyterian is a mission-driven, not-for-profit organization serving New Mexico with nine hospitals, a statewide health plan, and a growing multi-specialty medical group. 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 USD $37.58/Hr. Compensation Disclaimer 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.
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