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

This is a fully remote position, open to applicants in Alabama, +25 more states.

📋 Description

• Participate in comprehensive investigations concerning suspected fraud or abuse involving providers, pharmacies, employers, members, and brokers across Sentara Health Plans' offerings.

• Assess the quality of coding for pharmacies, physicians, ancillary services, and hospitals through regular desk audits and occasional on-site evaluations.

• Analyze reimbursement systems associated with health insurance claims processing.

• Ensure compliance with Optima Health policies and procedures for various product lines.

• Facilitate training related to investigations.

• Negotiate settlement agreements to resolve conflicts.

• Stay informed about relevant laws, regulations, and standards.

• Revise department policies and procedures as necessary.

• Assist in training personnel on updates to policies and procedures.

• Prepare routine reports for the department as required.

⛳️ Requirements

• A Bachelor's Degree is REQUIRED; a degree in a related field is preferred.

• Certification as a Professional Coder is REQUIRED, or must be obtained within 12 months of the hire date.

• A minimum of 5–8 years of relevant investigative experience OR 3–5 years of healthcare investigative experience is required.

• Experience in 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.

• Proven experience in conducting pre-pay investigations, provider risk assessments, data mining, and fraud, waste, and abuse (FWA) analysis, along with proactive identification of billing discrepancies and emerging trends among providers.

• Familiarity with data analytics to pinpoint high-risk providers and claims for pre-payment review in a healthcare payer, SIU, Program Integrity, or Payment Integrity environment is highly preferred.

• Additional preferred qualifications include 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 have completed the FBI Training Program (FBITP) - Criminal Investigator Training Program (CITP) may be considered equivalent to AHFI.

• Must be available to work from 8am to 5pm EST, Monday through Friday.

• Ability to travel to Virginia Beach once a year is required.

🏝️ Benefits

• Medical, Dental, and Vision plans.

• Adoption, Fertility, and Surrogacy Reimbursement of up to $10,000.

• Paid Time Off and Sick Leave.

• Paid Parental and Family Caregiver Leave.

• Emergency Backup Care.

• Long-Term, Short-Term Disability, and Critical Illness plans.

• Life Insurance.

• 401k/403B with Employer Match.

• Tuition Assistance of $5,250 per year and discounted educational opportunities through Guild Education.

• Student Debt Pay Down of $10,000.

• Pet Insurance.

• Legal Resources Plan.

• Annual discretionary bonus opportunity based on established criteria and employee eligibility.

• Shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities may be available.

• A family-friendly culture.

• Opportunities for personal development and career growth.

• A tobacco-free environment.