Associate Fraud and Abuse Investigator

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/Travel: Remote for candidates in listed states;
Travel to Virginia Beach 1x a year.

• 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.
• Contribute to the review of the quality of pharmacy, physician, ancillary and hospital-based coding in routine desk audits and occasional on-site audits.
• Contribute to the review of reimbursement systems related to health insurance claims processing and ensure adherence to policies and procedures for its various product offerings.
• Specific progression of responsibility follows 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 refer to Investigator for investigation or settlement.
• Assure accurate reimbursement is obtained and coding practices are compliant.
• Maintain comprehensive case files.
• Participate in special projects as required.

City/State: Norfolk, VA

Work Shift: 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.
• Contribute 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 refer to Investigator for investigation or settlement.
• Maintain comprehensive case files.
• Assures accurate reimbursement is obtained and coding practices are compliant.
• Participates in special projects as required.

• Education: Bachelor's Degree REQUIRED OR a minimum of 2 years combined experience 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). Certified Fraud Examiner (CFE) OR Accredited Health Care Fraud Investigator (AHFI) preferred.
• Experience: Job skills including Professional Writing, Verbal Communication, Time Management, Complex Problem Solving/Critical Thinking, Microsoft Excel and Word, Microsoft Access and Outlook.

• 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
• Tution Assistance – $5,250/year and discounted educational opportunities
• Student Debt Pay Down – $10,000
• Reimbursement for certifications and CEUs
• Pet Insurance
• Legal Resources Plan

Equal Opportunity: Sentara Health Plans is an equal opportunity employer and values diversity and inclusion. This is a tobacco-free environment. Remote positions are available in listed states: AL, DE, FL, GA, , IN, KS, LA, ME, MD, MN, NE, NV, NH, NC, ND, OH, OK, PA, SC, SD, TN, TX, UT, VA, WA, WV, WI, WY.