Coder-Healthcare Fraud Investigator

Overview

Now hiring a Coder-Healthcare Fraud Investigator

 

The SIU Investigator III supports Program Integrity Department initiatives at Presbyterian Health Plan. The Special Investigative Unit (SIU) Investigator III is responsible for conducting medium to highly complex reviews into suspected or actual healthcare fraud, waste, or abuse with respect to provider, pharmacy, employee, member, and broker interactions 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; requesting and reviewing 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 fraud, waste and abuse 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.

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 based Rev Hugh Cooper Admin Center
• 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, Law Enforcement Background, Ability to perform on site audits

Qualifications

• Bachelors 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

• Medium to high complexity reviews/investigations involving provider, pharmacy, employee, member, and broker issues
• 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
• Resolving conflict that arises from provider audit results and/or issues resulting from a fraud, waste, or abuse investigation
• Conduct research into coding rules and/or guidelines, or other state or federal rules and/or laws depending on the nature of the suspect fraud, waste, or abuse
• Maintains caseload and manages daily case review assignments and productivity standards with attention and accountability towards achieving a quality product
• Monitor cases post-audit to determine if continued aberrancies exist that require additional follow-up and reviewIntermediate level of:<