Coder-Healthcare Fraud Investigator

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The SIU Investigator III supports Program Integrity efforts at Presbyterian Health Plan by conducting complex investigations into suspected healthcare fraud, waste, or abuse across providers, pharmacies, employees, members, and brokers. Responsibilities include reviewing medical records, identifying improper billing or coding practices, interviewing involved parties, coordinating overpayment recovery, and educating on documentation standards. Ideal candidates bring strong experience in healthcare claims investigations, especially within Medicaid, Medicare, Marketplace, and commercial health plans.

Some key responsibilities include:

• Conduct complex investigations involving providers, pharmacies, employees, members, and brokers.

• Perform detailed medical coding audits and analyze referral-based fraud, waste, or abuse cases.

• Prepare accurate reports, legal documents, and referrals for government agencies.

• Maintain thorough case documentation in the SIU case management system.

• Communicate effectively with government agencies, providers, and internal teams.

• Use multiple systems to analyze claims and detect fraudulent patterns.

• Research coding rules and regulations to support investigations.

• Resolve conflicts from audit findings and manage post-audit case reviews.

• Collaborate on investigations and recommend process improvements.

• Conduct audits, recover overpayments, and educate providers on billing practices.

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)

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 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. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

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.