Associate Fraud and Abuse Investigator

City/State

Work Shift

Overview:

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 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:

To apply, please go to www.sentaracareers.com and use the following as your Keyword Search: JR-77536

Talroo-Health Plan

Keywords: Healthcare, Health Plan, Remote, Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington (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 Coder (CPC), Certified Fraud Examiner (CFE), Accredited Health Care Fraud Investigator (AHFI), Federal Bureau of Investigation Training Program (FBITP) - Criminal Investigator Training Program (CITP); Certified Forensic Interviewer (CFI), Certified Fraud Specialist (CFS), Certified Professional Coder (CPC) or Certified in Healthcare Compliance (CHC), Fraud, Waste, Abuse, Program Integrity, FWA, PI, Professional Writing, Verbal Communication, Time Management, Complex Problem Solving/Critical Thinking, Microsoft Excel and Word, Microsoft Access and Outlook

Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

In support of our mission “to improve health every day,” this is a tobacco-free environment.

For positions that are available as remote work, Sentara Health employs associates in the following states:

Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.