[Hiring] Associate Fraud and Abuse Investigator @Sentara Health

Role Description

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, ID, IN, KS, LA, ME, MD, MN, NE, NV, NH, ND, OH, OK, PA, SC, SD, TN, TX, UT, WA, WV, WI, WY! With travel to 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 as 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.

Qualifications

• 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
• 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.

Requirements

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

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