This opportunity is open to remote applicants in the United States, with the exception of the following states: Washington, Wyoming, North Dakota, and Ohio.
Summary: Identify, detect and investigate all allegations of fraud and abuse related to member, provider, subcontractor, broker/agent, employee and employer group. Research may relate to eligibility, claims payment, benefits, prior authorization/referrals, pharmacy review, provider and member contract review, provider license verification, etc. Coordinator will render initial decision regarding resolution of fraud and abuse issue based on completed research. Responsible for researching and compiling documentation that may be reported to external regulatory and law enforcement agencies, including but not limited to, New Mexico Human Services Department, NM Insurance Fraud Bureau, Office of Personnel Management, US Department of Health & Human Services Office of Inspector General and New Mexico Board of Pharmacy Diversion Unit. Research and audit for accurate provide payments. Develop administrative hearing packets and assist with facilitation of hearings.
*Identifies, detects and investigates allegations of fraud and abuse and completes investigations within policy timelines as defined by the appropriate regulatory body. *Review and coordinate detailed research, gather and prepare the documentation (from internal and external resources) related to fraud and abuse activity to develop a complete file. Uses available documentation including DART, provider manuals, member contracts and online policies and procedures 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 provide payments. *Develop administrative hearing packets and assist with facilitation of hearings. *Prepare and submit the documentation and provide feedback for all suspicious activities to the SIU Project Manager to present to the appropriate regulatory agency. *Produce and maintain required tracking and trending reports of suspected fraud and abuse files. *Provide feedback and process improvement recommendations to appropriate health plan 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 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 into the matter to resolve issues of fraud and abuse not previously resolved by such business units. *Responsible for application of contract language from both member contracts and employer contracts in researching and deciding the outcome fraud and abuse issues. *Presents completed research file along with initial recommendation for determination to SIU Project Manager for review and final approval within the time period necessary to remain in compliance with regulatory requirements for fraud and abuse. *Assists in preparation of hearing packets for fraud and abuse cases. *Responsible for file preparation and document preparation for all regulatory audit activities. *Responsible to know all regulatory requirements for fraud and abuse processing. *Must be familiar with claims processing standards and requirements as well as be well versed in other PHP/PIC functions, such as standards for member enrollment/disenrollment, routine Member Services functions related to eligibility/assignments and Health Services functions related to prior authorization and review of medical requests. Identifies errors and inconsistencies that require revisions to guidelines or system modifications, bringing such errors to the attention of appropriate personnel in each affected department or quality committee responsible for addressing such processes. *Responsible for logging of all fraud 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. *May be responsible for assessment of application of proper claims coding guidelines. Responsible for collaborating with coding consultant when necessary to determine if adjustments are necessary, or guidelines are appropriate. *Responsible for monitoring effectuation of all resolutions/outcomes as a result of the fraud and abuse process. *Assists in the development of process improvement functions that result from fraud and abuse processing. *Perform other functions as required or duties as assigned
2-3 years college level courses, 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. Prefer one year experience in interpretation of NM Medicaid Managed Care regulations, NM Department of Insurance regulations, and Medicare Advantage program regulations. Demonstrated ability to communicate effectively in person, via telephone, and in writing with members, physicians and other health care providers. 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.
Education: Essential: * Associate Degree
Internal Number: 2020-16558
About Presbyterian Healthcare Services
Presbyterian Healthcare Services is a 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, it is the state's largest private employer with approximately 11,000 employees.
Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans.
We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.
About New Mexico
New Mexico's unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque's International Balloon Fiesta, Los Alamos' nuclear scientists, Roswell's visitors from outer space, and Santa Fe's artists, and you get an eclectic mix of people, places and experiences tha...t make this state great.
Cities in New Mexico are continually ranked among the nation's best places to work and live by Forbes magazine, Kiplinger's Personal Finance, and other corporate and government relocation managers like Worldwide ERC.
New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.
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