Healthcare Investigator

4 weeks ago

Albuquerque, New Mexico, United States Presbyterian Healthcare Services Full time
Job Title: Healthcare Investigator

We are seeking a skilled Healthcare Investigator to join our team at Presbyterian Healthcare Services. As a Healthcare Investigator, you will play a critical role in identifying and investigating suspected or actual healthcare fraud, waste, or abuse.

Responsibilities:
  • Conduct medium to high complexity reviews and investigations involving provider, pharmacy, employee, member, and broker issues.
  • Perform in-depth and complex medical coding audits in an accurate and timely manner.
  • Develop and maintain accurate, current, and detailed case information in the SIU case management system.
  • Interface with government agencies, providers, and internal departmental collaboration.
  • 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.
Requirements:
  • Bachelor's degree, plus three years related healthcare experience required.
  • 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).
Benefits:

We offer a comprehensive benefits package, including medical, dental, vision, short-term and long-term disability, group term life insurance, and other optional voluntary benefits. Our Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being.

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.

Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan, and a growing multi-specialty medical group.

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