Associate Fraud and Abuse Investigator

City/State
Norfolk, VA

Work Shift
First (Days)

Overview:

Sentara Health Plan is currently hiring an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) Remote!

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

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

Location:
This position is remote for candidates that live in the following states: VA, NC, AL, DE, FL, GA, , IN, KS, LA, ME, MD, MN, NE, NV, NH, ND, OH, OK, PA, SC, SD, TN, TX, UT, WA, WV, WI, WY! With travelto Virginia Beach 1x a year.

Job 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.
• 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 policies and procedures for its various product offerings.
• Specific progression of responsibility is a follows dependent upon education, certifications, and experience:

- Triage and prioritize leads/member complaints from internal sources.

- Review and assess incoming referrals;
Assist in the investigation of potential fraud, waste, and abuse.

- Conduct research in support of an investigation.

- Collect and evaluate potential suspicious patterns in claims data, provider enrollment data, and other sources and refers to Investigator for investigation or settlement.

- Assures accurate reimbursement is obtained and coding practices are compliant.

- Maintain comprehensive case files.

- Participates in special projects as required.

Education:

• Bachelor's Degree REQUIRED OR
• Minimum of 2 years combined experience required in Medical Coding OR Healthcare (Medical Chart Review/Insurance Billing) OR Internal/External Audit OR Regulatory/Compliance OR Claims Investigations OR Criminal Investigation/White Collar Crime REQUIRED

Certifications/Licenses:

• Certified Professional Coder (CPC)
  REQUIRED (or achieved within 12 months of hire date)
• Certified Fraud Examiner (CFE) OR Accredited Health Care Fraud Investigator (AHFI)
  preferred.

Experience:

• Job skills:
  Professional Writing, Verbal Communication, Time Management, Complex Problem Solving/Critical Thinking, Microsoft Excel and Word, Microsoft Access and Outlook

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:

$22.36 hour- $37.26/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
and use the following as your Keyword Search:
JR-92935

Talroo-Health Plan

(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…