Coder-Healthcare Fraud Investigator

Presbyterian Healthcare Services

9d•$51,210 - $78,166•Remote

About The Position

Build your Career. Make a Difference. Presbyterian is hiring a skilled Fraud Investigator to join our team. 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.

Requirements

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

Nice To Haves

Certified Professional Medical Auditor (CPMA) through the AAPC
Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI)

Responsibilities

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.