Senior Fraud and Abuse Investigator​/CPC​/CFI​/CFS​/CHC​/CFE​/AHFI - Remote

Overview

Sentara Health Plan is currently hiring a Senior Fraud and Abuse Investigator/CPC/CFI/CFS/CHC/CFE/AHFI - Remote!

Full-time, permanent position (40 hours)

8am to 5pm EST, M-F

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

Norfolk, VA

First (Days)

• 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.
• 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.

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

• 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).

• 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
• Experience conducting pre-pay investigations, provider risk assessments, data mining, fraud, waste and abuse (FWA) analysis, and proactive identification of billing anomalies and emerging provider trends. Experience utilizing data analytics to identify high-risk providers and claims for pre-payment review within a healthcare payer, SIU, Program Integrity, or Payment Integrity environment is strongly preferred

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…