Coder-Healthcare Fraud Investigator

Presbyterian is seeking a talented Coder-Healthcare Fraud Investigator.

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.

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

Ideal Candidate:

The ideal candidate has extensive experience investigating healthcare claims fraud, waste, and abuse-particularly within Medicaid, Medicare, Marketplace, and commercial plans-and is skilled in medical record review, billing analysis, and stakeholder interviews.

• 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)

• 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.

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.