Senior Fraud and Abuse Investigator – CPC, CFI, CFS, CHC, CFE, AHFI

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🔥 0 minutes ago

🏈 Alabama, Florida, +24 more states – Remote

🏈 Alabama – Remote 🐊 Florida – Remote 🥔 Idaho – Remote 🌪️ Kansas – Remote ⚜️ Louisiana – Remote 🦞 Maine – Remote 🌾 Nebraska – Remote 🎰 Nevada – Remote 🗻 New Hampshire – Remote 🌲 North Carolina – Remote 🌾 North Dakota – Remote 🏈 Ohio – Remote 🌪️ Oklahoma – Remote 🦀 Maryland – Remote ❄️ Minnesota – Remote 🔔 Pennsylvania – Remote 🌴 South Carolina – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote ⚔️ Virginia – Remote ☕ Washington – Remote ⛰️ West Virginia – Remote 🧀 Wisconsin – Remote 🦬 Wyoming – Remote

💵 $29 - $48 / hour

⏰ Full Time

🟠 Senior

👻 Ghost score 0%

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Sentara Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1890

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

Sentara Health is a leading healthcare system that operates over 300 sites of care in Virginia and northeastern North Carolina, including 12 acute care hospitals. The company is dedicated to providing exceptional patient care, fostering professional development, and maintaining a diverse workforce. Sentara Health aims to improve health every day and has been recognized for its clinical and operational performance, being named one of the top 15 health systems by IBM Watson Health. The organization supports its employees in achieving their full potential and encourages growth and innovation in the healthcare sector.

📋 Description

• Contribute to in-depth investigations of suspected fraud or abuse involving providers, pharmacies, employers, members, and brokers across Sentara Health Plans' products • Review the quality of pharmacy, physician, ancillary, and hospital coding through routine desk audits and occasional on-site audits • Review reimbursement systems related to health insurance claims processing • Ensure adherence to Optima Health policies and procedures for various product offerings • Conduct investigation-related training • Negotiate settlement agreements to resolve disputes • Maintain current knowledge of relevant laws, regulations, and standards • Update department policies and procedures • Assist in training staff on policy and procedure changes • Prepare 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 • 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 strongly preferred • 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) • Federal Agents who completed the FBI Training Program (FBITP) - Criminal Investigator Training Program (CITP) may be considered equivalent to AHFI • Availability to work 8am–5pm EST, Monday–Friday • Ability to travel to Virginia Beach once a year

🏖️ 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 • Annual discretionary bonus opportunity subject to established system and employee eligibility criteria • Shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities may be available • Family-friendly culture • Opportunities for development and growth • Tobacco-free environment