Senior Fraud and Abuse Investigator- Remote

Status: Full-time, permanent position (40 hours)

Work hours: 8am to 5pm EST, M-F

Remote opportunities available in the following states: Virginia, North Carolina, Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington (state), West Virginia, Wisconsin, Wyoming. With travel to Virginia Beach 1x a year.

Overview

Responsible for contributing to in-depth investigations for suspected fraud or abuse with respect to provider, pharmacy, employer, member, and broker interactions involving the full range of products at Sentara Health Plans. Responsible for contributing to the review of the quality of pharmacy, physician, ancillary and hospital based coding in routine desk audits as well as occasional on-site audits. Contribute to the review of reimbursement systems relating to health insurance claims processing and ensures adherence to Optima Health policies and procedures for its various product offerings. Specific progression of responsibility is a follows dependent upon education, certifications, and experience:

Conducts investigation-related training.
Negotiates settlement agreements to resolve disputes.
Maintain current knowledge of relevant laws, regulations and standards.
Updates department policies and procedures and assists in training staff on changes.
Prepares routine department reporting as needed.

Education

• Bachelor's Degree REQUIRED; Degree in a related field of study preferred.

Certification/Licensure

• Certified Professional Coder REQUIRED  (or achieved within 12 months of hire date)

• Additional Preferred Qualifications:
  Certified Forensic Interviewer (CFI)
  Certified Fraud Specialist (CFS)
  Certified Professional Coder (CPC) or
  Certified in Healthcare Compliance (CHC)
  Certified Fraud Examiner (CFE) OR Accredited Health Care Fraud Investigator (AHFI) preferred. (Note: Federal Agents who have successfully completed the Federal Bureau of Investigation Training Program (FBITP) - Criminal Investigator Training Program (CITP) would be considered equivalent to the AHFI).

Experience

• Minimum 5-8 years of related investigative experience OR 3 - 5 years of related health care investigative experience

• Healthcare, Coding, Audit, Investigations, Regulatory, and/or Compliance 5 years REQUIRED -OR- Healthcare Investigation related to Coding, Audit, Regulatory, and/or Compliance 3 years REQUIRED

Sentara Health Plans provides health plan coverage to close to one million members in Virginia. We offer a full suite of commercial products including employee-owned and employer-sponsored plans, as well as Individual & Family Health Plans, Employee Assistance Programs and plans serving Medicare and Medicaid enrollees.

Our quality provider network features a robust provider network, including specialists, primary care physicians and hospitals.

We offer programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health services—all to help our members improve their health.

Our success is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and growth. 

Be a part of an excellent healthcare organization that cares about our People, Quality, Patient Safety, Service, and Integrity. Join a team that has a mission to improve health every day and a vision to be the healthcare choice of the communities that we serve!

We provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay rate for Full Time employment is:

$29.21 hour- $48.68/hour. Additional compensation may be available for this role such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.

To apply, please go to www.sentaracareers.com and use the following as your Keyword Search: JR-92443

Talroo-Health Plan

Keywords: Healthcare, Health Plan, Remote, Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington (state), West Virginia, Wisconsin, Wyoming, Bachelor's Degree, Medical Coding, Medical Chart Review, Insurance Billing, Internal/External Audit, Regulatory, Compliance, Claims Investigations, Criminal Investigation, White Collar Crime, Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), Accredited Health Care Fraud Investigator (AHFI), Federal Bureau of Investigation Training Program (FBITP) - Criminal Investigator Training Program (CITP); Certified Forensic Interviewer (CFI), Certified Fraud Specialist (CFS), Certified Professional Coder (CPC) or Certified in Healthcare Compliance (CHC), Fraud, Waste, Abuse, Program Integrity, FWA, PI, Professional Writing, Verbal Communication, Time Management, Complex Problem Solving/Critical Thinking, Microsoft Excel and Word, Microsoft Access and Outlook