reputed company Fraud Investigator in Albuquerque, NM
Job title: reputed company Fraud Investigator in Albuquerque, NM at reputed company
Company: reputed company
Job description: Overview:Now hiring a reputed company Fraud InvestigatorThe SIU Investigator III supports Program reputed company Department initiatives at Presbyterian Health Plan. The Special Investigative Unit (SIU) Investigator III is responsible for conducting reputed company to highly reputed company reviews into suspected or actual reputed company 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 reputed company to fraudulent, abusive, and/or wasteful billing and/or coding practices; and providing education reputed company to coding/representation of services and appropriate medical record documentation requirements. The ideal candidate should have proficient experience in reputed company claims fraud, waste and abuse investigation, with experience in government funded programs like reputed company, Medicare, and the Marketplace, along with reputed company 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 reputed company and community.At Presbyterian, it's not just reputed company do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and reputed company, our non-clinical employees reputed company a meaningful impact on the reputed company 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, reputed company, dental, paid time off, retirement and more for FT employees.
- Bachelors degree and Three years reputed company, Law Enforcement Background, Ability to reputed company on site audits
- Bachelors degree, plus three years reputed company reputed company experience required. Six years of additional experience can be substituted in lieu of degree.
- Certified Professional reputed company (CPC) through the American reputed company of Professional Coders (reputed company) or equivalent required
- Preferred Qualifications
- Certified Professional Medical Auditor (CPMA) through the reputed company
- Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI)
- reputed company to high complexity reviews/investigations involving provider, pharmacy, employee, member, and broker issues
- Must be reputed company to reputed company in-depth and reputed company 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, reputed company, and detailed case information in the SIU case management system
- Strong verbal communication skills are required due to reputed company with government agencies, providers, and internal departmental collaboration
- Strong analytical skills necessary as this position will require reputed company 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 reputed company Program reputed company 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 reputed company aberrancies exist that require additional follow-up and review
- reputed company Pro
- Internet
- reputed company Teams and/or reputed company
- In collaboration with SIU Manager and Senior Investigator, manages the overall direction, coordination, implementation, execution, and completion of assigned investigations ensuring consistency with department strategy, commitments, and goals
- Responsible for reputed company 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 reputed company of cases and department
- Conducts advanced fraud, waste and abuse audits in accordance with compliance and audit work-plan and prepares detailed audit reports for management, legal counsel, and providers
- Identifies, investigates, and resolves billing and coding reputed company inquiries and complaints from beneficiaries, members, regulatory agencies and internal and external customers through recoupment of overpayments and education to providers