Specialist Investigative Unit Coordinator

Now hiring a Specialist Investigative Unit Coordinator. Albuquerque Metro residents only

Identify, detect, investigate, and report all allegations of healthcare fraud, waste, and abuse related to members, providers, subcontractors, brokers/agents, employees and employer groups.

Research may relate to eligibility, claims payment, benefits, prior authorization/referrals, pharmacy review, provider and facility contract review, provider license verification, personal care option review, and any other circumstances that may present regarding the initial triage and referral intake process within the Special Investigative Unit (SIU) at Presbyterian Health Plan.

SIU Coordinator will conduct initial intake of all referrals made to the SIU and follow the triage process per unit policy and procedure and in alignment with state and federal rules and regulations for the indicated line of business. The SIU Coordinator will comply with all required contractual and regulatory timelines, and will manage caseloads in an effective, accurate, and timely manner.

Responsible for researching and compiling documentation that may be reported to external regulatory and law enforcement agencies, including but not limited to: State of New Mexico Human Services Department (HSD), HSD Office of Inspector General, State of New Mexico Medicaid Fraud and Elder Abuse Division, State of New Mexico Office of the Superintendent of Insurance, United States Department of Health and Human Services Office of Inspector General, and New Mexico Board of Pharmacy Diversion Unit.

How you belong matters here.

We value our employees' differences and find strength in the diversity of our team and community.

At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.

Why Join Us

Full Time - Exempt: Yes
• Job is based Rev Hugh Cooper Admin Center
• Work hours: Weekday Schedule Monday-Friday
• Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees.

• Associates/Diploma required; 3 years of additional experience can be substituted in lieu of degree.
• Bachelors degree in healthcare related field preferred.
• Three to five years experience in HMO/MCO or health insurance environment required with emphasis in claims, member services, appeals and grievances or prior authorizations.
• Must obtain Healthcare Anti-Fraud Associate (HCAFA) designation from Americas Health Insurance Plans within six months of hire those already in the position will not be grandfathered must obtain designation.. *Prefer one year experience in interpretation of NM Medicaid Managed Care regulations, NM Office of Superintendent of Insurance regulations, and Medicare Advantage program regulations.
• Demonstrated ability to communicate effectively in person, via telephone, and in writing with members, providers, and other healthcare entities.
• Requires detailed research, coordination, and organizational skills.
• Must be able to work cooperatively with other employees and departments and function effectively under pressure.
• Familiarity with Windows and Microsoft Office products.

• Identifies, detects, investigates, and reports allegations of fraud, waste, and abuse and completes assigned investigations within policy timelines as defined by the appropriate regulatory body.
• Reviews and coordinates detailed research, gathers and prepares the documentation (from internal and external resources) related to fraud, waste, and abuse activity to develop a complete file. Uses available documentation including DART, provider manuals, member contracts, and internal policies and procedures, and external references to support accurate and consistent decisions relating to claims payment, authorizations, contractual issues, servicing and care standards, and all other operational aspects of the health plan.
• Research and audit for accurate provider payments.
• Participate in and take minutes for the Anti-Fraud, Waste, and Abuse Subcommittee.
• Produce and maintain required tracking and trending reports of suspected fraud, waste, and abuse files.
• Provide feedback and process improvement recommendations to appropriate health plan departments including quality, health services, pharmacy, credentialling, provider services, member services, under-writing, finance, claims recovery, legal/compliance departments and committees based on analysis and trending of fraud, waste, and abuse data and documentation.
• Required to communicate in writing with member, provider or designated representative; using the regulatory compliant format on all issues when correspondence is necessary. All written correspondence must be reviewed for regulatory statutes and requirements for a multitude of product line specified requirements. Must be able to articulate orally and in writing an understanding of complex issues and detailed action plans, while best representing the organization professionally.
• Responsible for reviewing research previously performed by Member Services, Provider Services , Care Unit staff or other departments and conducting more detailed investigative research to prepare the case for formal investigation by the SIU Investigators.
• Presents completed preliminary investigation, along with initial recommendation for determination to SIU Senior Investigator for review and final approval within the time period necessary to remain in compliance with regulatory requirements for fraud, waste, and abuse.
• Responsible for file preparation and document preparation for all regulatory audit activities, along with processing major mailings.
• Responsible to know all regulatory requirements for fraud, waste, and abuse processing.
• Responsible for logging of all fraud, waste, and abuse issues, and identification of all trends associated with such issues. Must be proficient with database entry and categorization of issue type, receipt date, timeframe for acknowledgement and resolution processing.
  Responsible for intake and accurate data entry of all subcontractors reports into the SIU case tracking tool within required timelines .
• Perform Administrative audits on all subcontractors with the assistance of the SIU Manager.
• Assists in the development of process improvement functions that result from fraud, waste, and abuse processing.
• Perform other functions as required or duties as assigned.

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

Inclusion and Diversity
Our culture is one of knowing and respecting our patients, members, and each other. We capture this in our Promise and CARES commitments.

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