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Sentara Health · 1 day ago

Senior Fraud and Abuse Investigator- Remote

United States

Full-time

Remote

Senior Level

$29.21/hr - $48.68/hr

5+ years exp

Sentara Health is currently hiring a Senior Fraud and Abuse Investigator to contribute to investigations of suspected fraud or abuse within their health plans. The role involves reviewing coding quality, reimbursement systems, and conducting training, while ensuring compliance with relevant laws and policies.

Hospital & Health Care

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 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

Qualification

Certified Professional CoderHealthcare InvestigationRegulatory ComplianceCertified Fraud ExaminerMedical CodingInternal/External AuditProfessional WritingComplex Problem SolvingMicrosoft ExcelMicrosoft WordMicrosoft AccessMicrosoft OutlookVerbal CommunicationTime Management

Required

Bachelor's Degree REQUIRED; Degree in a related field of study preferred

Certified Professional Coder REQUIRED (or achieved within 12 months of hire date)

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

Preferred

Certified Forensic Interviewer (CFI)

Certified Fraud Specialist (CFS)

Certified Professional Coder (CPC) or Certified in Healthcare Compliance (CHC)

Certified Fraud Examiner (CFE)

Accredited Health Care Fraud Investigator (AHFI)

Federal Agents who have successfully completed the Federal Bureau of Investigation Training Program (FBITP) - Criminal Investigator Training Program (CITP) would be considered equivalent to the AHFI

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

Reimbursement for certifications and free access to complete CEUs and professional development

Pet Insurance

Legal Resources Plan

Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.

Company

Sentara Health

Glassdoor3.7

Sentara Health, an integrated, not-for-profit health care delivery system, celebrates more than 135 years in pursuit of its mission - "we improve health every day." Sentara is one of the largest health systems in the U.S.

Founded in 1988

Hampton Roads, VA, US

10001+ employees