Remote Coder - Healthcare Fraud Investigator
Full Time
Albuquerque, NM 87113
Posted
Job description
Overview:
Job Description
Type of Opportunity: Full Time
FTE: 1.000000
Exempt: Yes
Work Schedule: Weekday Schedule Monday-Friday
This opportunity is open to remote applicants in the United States, with the exception of the following states:
Summary:
The SIU Investigator supports the compliance related activities of the Program Integrity Department. Responsible for conducting proficient reviews into suspected fraud, waste, or abuse with respect to provider, pharmacy, employer, member, and broker interactions involving the full range of products at Presbyterian. 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/representation of services and appropriate medical record documentation requirements. The ideal candidate should have proficient experience in claims fraud, waste and abuse investigation.
Qualifications:
Benefits:
Benefits
Benefits are effective day-one (for .45 FTE and above) and include:
About Us
Presbyterian Healthcare Services is 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, it is the state's largest private employer with approximately 11,000 employees.
Job Description
Type of Opportunity: Full Time
FTE: 1.000000
Exempt: Yes
Work Schedule: Weekday Schedule Monday-Friday
This opportunity is open to remote applicants in the United States, with the exception of the following states:
Washington, Wyoming, North Dakota, and Ohio. Must be able to work mountain time.
Summary:
The SIU Investigator supports the compliance related activities of the Program Integrity Department. Responsible for conducting proficient reviews into suspected fraud, waste, or abuse with respect to provider, pharmacy, employer, member, and broker interactions involving the full range of products at Presbyterian. 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/representation of services and appropriate medical record documentation requirements. The ideal candidate should have proficient experience in claims fraud, waste and abuse investigation.
Qualifications:
Requirements:
- Associates degree and 3 years related experience required. 3 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:
Proficient level of:
Proficient communication:
Proficient communication:
Intermediate level of:
Proficient using:
Proficient level of:
- Investigational experience
- Procedural coding
- Technical writing skills
- Analytical skills
- Ability to learn
- Critical thinking and attention to detail
Proficient communication:
- Facilitating meetings
- Authoring articles & letter members & providers
- Engaging with all levels of staff and management within the organization, committee members, leadership, as well as the public
- 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
Proficient communication:
- Resolving conflicts
- Negotiating with vendors
Intermediate level of:
- Compliance with specifics to Healthcare accreditation and CMS.
- Managed Care and awareness enterprise operations, functions & processes.
Proficient using:
- MS Office
- Adobe Pro
- Internet
- Skype
- In collaboration with Senior Investigator and Manager, manages the overall direction, coordination, implementation, execution, and completion of assigned investigations ensuring consistency with department strategy, commitments, and goals.
- May be responsible for concurrent and/or retrospective review, data abstraction, analysis, identification of critical issues, process improvement support, required education, and assisting with measurement of performance metrics.
- Serves as resource recommending process modifications and practice changes to improve efficiency, effectiveness, and reliability of processes and systems.
- Builds and develops collaborative relationships vital to the success of cases and department.
- Conducts advanced fraud, waste and abuse audits in accordance with compliance and audit work-plan and prepare detailed audit reports for management, legal counsel, and providers.
- Identifies, investigates, and resolves billing and coding related inquiries and complaints from beneficiaries, members, regulatory agencies and internal and external customers through recoupment of overpayments and education to providers
Benefits:
Benefits
Benefits are effective day-one (for .45 FTE and above) and include:
- Competitive salaries
- Full medical, dental and vision insurance
- Flexible spending accounts (FSAs)
- Free wellness programs
- Paid time off (PTO)
- Retirement plans, including matching employer contributions
- Continuing education and career development opportunities
- Life insurance and short/long term disability programs
About Us
Presbyterian Healthcare Services is 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, it is the state's largest private employer with approximately 11,000 employees.
Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans.
We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.
About New Mexico
New Mexico's unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque's International Balloon Fiesta, Los Alamos' nuclear scientists, Roswell's visitors from outer space, and Santa Fe's artists, and you get an eclectic mix of people, places and experiences that make this state great.
Cities in New Mexico are continually ranked among the nation's best places to work and live by Forbes magazine, Kiplinger's Personal Finance, and other corporate and government relocation managers like Worldwide ERC.
New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.
About New Mexico
New Mexico's unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque's International Balloon Fiesta, Los Alamos' nuclear scientists, Roswell's visitors from outer space, and Santa Fe's artists, and you get an eclectic mix of people, places and experiences that make this state great.
Cities in New Mexico are continually ranked among the nation's best places to work and live by Forbes magazine, Kiplinger's Personal Finance, and other corporate and government relocation managers like Worldwide ERC.
New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
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