City/State

Work Shift

Overview:

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

• 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

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-105160

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), Fraud, Waste, Abuse, Program Integrity, FWA, PI, SIU, Special Investigations Unit, Certified Forensic Interviewer (CFI), Certified Fraud Specialist (CFS), Certified Professional Coder (CPC), Certified in Healthcare Compliance (CHC), Certified Fraud Examiner (CFE) OR Accredited Health Care Fraud Investigator (AHFI) , Bureau of Investigation Training Program (FBITP) - Criminal Investigator Training Program (CITP)

Benefits: Caring For Your Family and Your Career

• Medical, Dental, Vision plans

• Adoption, Fertility and Surrogacy Reimbursement up to $10,000

• Paid Time Off and Sick Leave

• Paid Parental & Family Caregiver Leave

• Emergency Backup Care

• Long-Term, Short-Term Disability, and Critical Illness plans

• Life Insurance

• 401k/403B with Employer Match

• Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education

• Student Debt Pay Down – $10,000

•Pet Insurance 
•Legal Resources Plan
•Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.

Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

In support of our mission “to improve health every day,” this is a tobacco-free environment.

For positions that are available as remote work, Sentara Health employs associates in the following states:

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, West Virginia, Wisconsin, and Wyoming.