Fraud and Abuse Investigator

City/State Norfolk, VA

Work Shift

Overview:

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

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: Virginia, North Carolina, 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; With travel to Virginia Beach 1x a year.

Job Summary:

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 through Sentara Health Plans lines of business. 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. Contributes to the review of reimbursement systems relating to health insurance claims processing and ensures adherence to health plan policies and procedures for its various product offerings.

Job Description:

• 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.
• Assists in drafting settlements

Education:

• Bachelor's degree preferred

Certifications/Licenses:

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

Experience:

• 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. 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 is preferred.

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

To apply, please go to and use the following as your Keyword Search: JR-107986

Talroo-Health Plan

Keywords: Healthcare, Health Plan, Remote, Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minneso