[Hiring] Senior Fraud and Abuse Investigator @Sentara Health

Role Description

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.

• Conducts investigation-related training.
• Negotiates settlement agreements to resolve disputes.
• Maintain 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.

Qualifications

• Bachelor's Degree REQUIRED; Degree in a related field of study preferred.
• 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)
• Certified in Healthcare Compliance (CHC)
• Certified Fraud Examiner (CFE) OR Accredited Health Care Fraud Investigator (AHFI) preferred.

Requirements

• 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.
• Experience conducting pre-pay investigations, provider risk assessments, data mining, fraud, waste and abuse (FWA) analysis, and proactive identification of billing anomalies and emerging provider trends.
• Experience utilizing data analytics to identify high-risk providers and claims for pre-payment review within a healthcare payer, SIU, Program Integrity, or Payment Integrity environment is strongly 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
• Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.