Coder-Senior Healthcare Fraud Investigator

Overview

Now hiring a Coder-Senior Healthcare Fraud Investigator

The Senior Investigator supports the Program Integrity Manager and department investigators. This role assists with developing, implementing, and performing fraud, waste, and abuse related auditing and monitoring activities. This includes the identification, investigation and correction of fraudulent, wasteful, and/or abusive billing and coding practices; coordination of recovery of overpayments related to fraudulent and/or abusive billing and coding practices; and providing education related to coding, medical record documentation requirements. This person must develop excellent professional relationships with internal and external partners and providers and their representatives, other payers, regulatory agencies, local healthcare law enforcement and accrediting bodies. The ideal candidate should have advanced experience in claims fraud, waste and abuse investigation

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

Ideal Candidate:

• Bachelors degree and 5 years Healthcare Coding, Healthcare/Investigations, Internal/External Audit, OR Regulatory/Compliance). Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI)

Qualifications

• Bachelors degree and 5 years related experience required (related experience includes 5 years Healthcare Coding, 5 years Healthcare/Investigations, 5 years Internal/External Audit, OR 5 years
• Regulatory/Compliance).
• 6 years of additional experience can be substituted in lieu of degree.
• CPC or equivalent required
• Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) preferred

Responsibilities

• Investigational experience
• Procedural coding
• Technical writing
• Analysis
• Ability to learn
• Critical thinking and attention to detail.
• Advanced communication:
• Facilitating meetings
• Authoring articles & letters to members & providers
• Engaging with all levels of staff and management within the organization, committee members, as well as the public
• Proofreading work of team members
• Broad view of enterprise
• Demonstrated ability to communicate effectively in person and via telephone with members, employer groups, physicians, and physician office staff using strong dialogue and customer service competencies
• Advanced levels of:
• Compliance
• Managed Care
• Proficient using:
• MS Office
• Adobe Pro
• Internet
• In collaboration with the Manager, guides others to develop build and update work plans, tasks, timelines, measurements, and reports
• Implement processes
• Works collaboratively with Program Integrity investigators (including performing quality check on work, assisting in research, assisting with appropriate coding determinations in addition to the responsibilities outlined below)
• Assist with the analyzation and interpretation of medical records pertaining to fraud, waste, and abuse investigations
• Help to determines appropriateness of billing and reimbursement
• Identifies gaps in knowledge and provides training to investigative team and organization
• Abstracts CPT, HCPCS, Revenue Codes, DRG, and ICD-9/ICD-10 from medical records.
• Responsible for maintaining current knowledge of coding guidelines and relevant federal and/or state regulations
• Performs other functions as required

Benefits

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 ensure the patients, members and communities we serve can achieve their best health. We are a 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.

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.

Maximum Offer for this position is up to

USD $45.82/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.

Read Full Description