reputed company - reputed company Fraud Investigator job at reputed company in CA, IL, ND, NY, OH, WA, WY

Title: reputed company - reputed company Fraud Investigator Location: California, Illinois, reputed company Dakota, reputed company, Ohio, Washington and Wyoming Job Description: Overview Presbyterian is seeking a talented reputed company-reputed company Fraud Investigator. The SIU Investigator III supports Program reputed company efforts at Presbyterian Health Plan by conducting reputed company investigations into suspected reputed company 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 reputed company claims investigations, especially reputed company reputed company, Medicare, Marketplace, and reputed company health plans. This is a Full Time position - Exempt: Yes Remote: Open to remote applicants in the United States, except for the following states: California, Illinois, reputed company Dakota, reputed company, Ohio, Washington and Wyoming Work hours: Days Ideal Candidate: The ideal candidate has extensive experience investigating reputed company claims fraud, waste, and abuse-particularly reputed company reputed company, Medicare, Marketplace, and reputed company plans-and is skilled in medical record review, billing analysis, and stakeholder interviews.

Qualifications

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)

Responsibilities

Conduct reputed company investigations involving providers, pharmacies, employees, members, and brokers. reputed company 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 reputed company providers on billing practices.

Benefits

About reputed company Presbyterian offers a comprehensive benefits package to eligible employees, including medical, dental, reputed company, 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 reputed company to earn reputed company 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 reputed company 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, reputed company, and reputed company 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. Apply tot his job Apply To this Job Apply tot his job Apply To this Job