[Hiring] Fraud and Abuse Investigator @Sentara Health

Role Description

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

• Responsible for contributing to in-depth investigations for suspected fraud or abuse involving provider, pharmacy, employer, member, and broker interactions.
• Contributes to the review of the quality of pharmacy, physician, ancillary, and hospital-based coding in routine desk audits and occasional on-site audits.
• Ensures adherence to health plan policies and procedures for various product offerings.

Key Responsibilities:

• Identify, investigate, analyze, and evaluate instances of potential fraud, waste, and abuse.
• Conduct interviews or correspond with patients, providers, witnesses, or other relevant parties to determine settlement, denial, or review.
• Analyze information gathered by investigation and report findings and recommendations as a written summary and/or presentation.
• Learn and conduct statistical sampling of complex medical claims.
• Assist in drafting settlements.

Qualifications

• Bachelor's degree preferred.
• Certified Professional Coder preferred (or achieved within 12 months of hire date).

Requirements

• 2 years combined experience required in Internal/External Audit OR regulatory/Compliance OR Healthcare preferred.
• Experience reviewing claims, analyzing data, identifying potential billing irregularities, and supporting pre-pay review activities preferred.
• Familiarity with healthcare claims, provider billing patterns, fraud, waste, and abuse (FWA) concepts, and the use of data analysis to identify claims or providers requiring further review preferred.

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.
• Opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria are met.