Senior Fraud and Abuse Investigator- Remote
About The Position
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. Specific progression of responsibility is a follows dependent upon education, certifications, and experience: 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.
Requirements
- 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
Nice To Haves
- Certified Forensic Interviewer (CFI)
- Certified Fraud Specialist (CFS)
- Certified Professional Coder (CPC) or Certified in Healthcare Compliance (CHC)
- Certified Fraud Examiner (CFE) OR Accredited Health Care Fraud Investigator (AHFI) preferred. (Note: 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).
Responsibilities
- Contributing to in-depth investigations for suspected fraud or abuse.
- Reviewing the quality of pharmacy, physician, ancillary and hospital based coding in routine desk audits as well as occasional on-site audits.
- Reviewing 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.
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.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Senior
Number of Employees
5,001-10,000 employees
