SIU Field Investigator

Overview

Presbyterian is seeking a SIU Field Investigator

The Special Investigative Unit (SIU) Field Investigator supports Program Integrity Department initiatives at Presbyterian Health Plan. The SIU Field Investigator is responsible for conducting announced and unannounced provider onsite audits of medium to high complexity related to suspected or actual healthcare fraud, waste, or abuse (FWA) 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; going onsite to the provider office and requesting and obtaining 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 FWA 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.

• This is a Full Time position - Exempt : Yes
• Job is based at Rev Hugh Cooper Admin Center
• Work hours : Days

Ideal Candidate : Bachelors Degree. Certified Professional Medical Auditor (CPMA) through the AAPC or Law Enforcement background

Qualifications

Responsibilities

Benefits

About Presbyterian Healthcare Services Presbyterian offers a comprehensive benefits package to eligible employees, including medical, dental, vision, disability coverage, life insurance, and optional voluntary benefits.

The Employee Wellness Rewards Program encourages staff to engage in health-enhancing activities—like challenges, webinars, and screenings—with opportunities to earn gift cards and other incentives.

As a mission-driven organization, Presbyterian is deeply committed to improving community health across New Mexico through initiatives like growers' markets and local partnerships. Founded in 1908, Presbyterian is a locally owned, not-for-profit healthcare system with nine hospitals, a statewide health plan, and a growing multi-specialty medical group. With nearly 14,000 employees, it is the largest private employer in the state, serving over 580,000 health plan members through Medicare Advantage, Medicaid, and Commercial plans.

AA / EOE / VET / DISABLED. PHS is a drug-free and tobacco-free employer with smoke-free campuses.

Maximum Offer for this position is up to USD $37.58 / Hr. Compensation Disclaimer The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.

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