Coder-Senior Healthcare Fraud Investigator

Presbyterian is seeking a talented Coder-Senior Healthcare Fraud Investigator

The Senior Investigator supports the Program Integrity Manager and department investigators. This role assists with developing, implementing, and performing fraud, waste, and abuse related auditing and monitoring activities. This includes the identification, investigation and correction of fraudulent, wasteful, and/or abusive billing and coding practices; coordination of recovery of overpayments related to fraudulent and/or abusive billing and coding practices; and providing education related to coding, medical record documentation requirements. The Senior Investigator must develop excellent professional relationships with internal and external partners and providers and their representatives, other payers, regulatory agencies, local healthcare law enforcement and accrediting bodies.

This is a Full Time position - Exempt: Yes
• Work hours: Days

Ideal Candidate:

The ideal candidate should have advanced experience in claims fraud, waste and abuse investigation.

• Bachelors degree and 5 years related experience required (related experience includes 5 years Healthcare Coding, 5 years Healthcare/Investigations, 5 years Internal/External Audit, OR 5 years
  Regulatory/Compliance).
• 6 years of additional experience can be substituted in lieu of degree.
• CPC or equivalent required
• Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) preferred

• Conducts investigations and analyzes medical records to identify fraud, waste, and abuse.

• Applies procedural coding expertise, including CPT, HCPCS, DRG, and ICD-9/ICD-10 abstraction.

• Demonstrates strong technical writing skills for reports, audits, and member/provider communications.

• Utilizes critical thinking and attention to detail in coding reviews and billing assessments.

• Communicates effectively across all organizational levels and with external stakeholders.

• Facilitates meetings, authors correspondence, and proofreads team documentation.

• Maintains advanced knowledge of compliance, managed care, and coding regulations.

• Proficient in MS Office, Adobe Pro, internet research, and virtual collaboration tools.

• Supports process implementation and guides development of work plans and performance metrics.

• Provides training, conducts quality checks, and collaborates with investigators to improve team effectiveness.

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.