Job Details

Overview

Sentara Health Plan is currently hiring a 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.

Responsibilities

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 as follows dependent upon education, certifications, and experience. Conducts investigation-related training. Negotiates settlement agreements to resolve disputes. Maintains 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.

Location & Work Schedule

City/State: Norfolk, VA

Work Shift: First (Days)

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 completed the FBI 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

Benefits

• 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
• Reimbursement for certifications and free access to complete CEUs and professional development
• Pet Insurance
• Legal Resources Plan
• Annual discretionary bonus if eligibility criteria are met

Equal Opportunity: Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its workforce. Diversity, inclusion, and belonging are guiding principles of the organization.

Note: For positions 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.