Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) - Remo
城市/州诺福克，VAWork Shift 多班工作可用概况：Sentara Health Plan 目前正在聘请一名与职人员有关欺诈和滥用调查员/认证专业编码器 (CPC) 远程！状态：全日制，永久职位 （40小时）工作时间：EST8点到下午5点，M-F 地点：本职位是以下州居住的候选人远程：NC,AL,DE,FL,GA,ID,IN,KS,LA,ME,MD,MN,NE,NV,NH,ND,OH,OK,PA,SC,SD,TN,TX,WA,WV,WI,WY!每年1次前往弗吉尼亚海的工作责任：·负责对提供商，药店，雇主，成员和经纪人互动涉及全系列产品的疑似欺诈或滥用进行深入调查。·负责在日常办公室审计以及偶尔现场审计中协助审查药房，医生，辅助机构和医院编码质量。· 促进有关医疗保险索赔处理的退款系统的审查，并确保其各种产品供应政策和程序遵守。·具体责任进展依赖于教育，认证和经验：- 审核和优先考虑来自内部来源的潜在投诉/成员投诉。- 审查并评估收到的推；协助调查可能的欺诈，浪费和滥用行为。- 进行研究支持调查。- 收集和评估索赔数据，供应商注册数据和其他来源中的潜在可疑模式，并向调查员提交调查或结算。-确保获得准确退款以及编码实践符合情况。- 维护全面的案例档案。- 根据需要参与特殊项目。教育：· 学士学位或要求 · 需要在医疗编码或医疗保健 （医学图表审查/保险账单）或内部/外部审计或监管/合规性或索赔调查或刑事调查/白领犯罪要求的最低2年的综合经验证书/许可证：· 认证专业编码器 (CPC) 要求 （或者从雇佣日期12个月内获得）· 认可欺诈检查员 (CFE) OR 认证卫生保健欺诈调查员 (AHFI)优先。工作技能：职业写作，口头沟通，时间管理，复杂问题解决/批判性思维，微软 Excel 和 Word,微软访问和 SentaraHealt Outlook
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City/State
Norfolk, VAWork Shift
Multiple shifts availableOverview:
Sentara Health Plan is currently hiring an Associate 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: VA, NC, AL, DE, FL, GA, ID, IN, KS, LA, ME, MD, MN, NE, NV, NH, ND, OH, OK, PA, SC, SD, TN, TX, UT, WA, WV, WI, WY! With travel to Virginia Beach 1x a year.
Job 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.
- 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 policies and procedures for its various product offerings.
- Specific progression of responsibility is a follows dependent upon education, certifications, and experience:
- Triage and prioritize leads/member complaints from internal sources.
- Review and assess incoming referrals; Assist in the investigation of potential fraud, waste, and abuse.
- Conduct research in support of an investigation.
- Collect and evaluate potential suspicious patterns in claims data, provider enrollment data, and other sources and refers to Investigator for investigation or settlement.
- Assures accurate reimbursement is obtained and coding practices are compliant.
- Maintain comprehensive case files.
- Participates in special projects as required.
Education:
- Bachelor's Degree REQUIRED OR
- Minimum of 2 years combined experience required in Medical Coding OR Healthcare (Medical Chart Review/Insurance Billing) OR Internal/External Audit OR Regulatory/Compliance OR Claims Investigations OR Criminal Investigation/White Collar Crime REQUIRED
Certifications/Licenses:
- Certified Professional Coder (CPC) REQUIRED (or achieved within 12 months of hire date)
- Certified Fraud Examiner (CFE) OR Accredited Health Care Fraud Investigator (AHFI) preferred.
Experience:
· Job skills: Professional Writing, Verbal Communication, Time Management, Complex Problem Solving/Critical Thinking, Microsoft Excel and Word, Microsoft Access and Outlook
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-107869
Talroo-Health Plan
Keywords: Healthcare, Health Plan, Remote, 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, Bachelor's Degree, Medical Coding, Medical Chart Review, Insurance Billing, Internal/External Audit, Regulatory, Compliance, Claims Investigations, Criminal Investigation, White Collar Crime, Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), Accredited Health Care Fraud Investigator (AHFI), Federal Bureau of Investigation Training Program (FBITP) - Criminal Investigator Training Program (CITP); Certified Forensic Interviewer (CFI), Certified Fraud Specialist (CFS), Certified Professional Coder (CPC) or Certified in Healthcare Compliance (CHC), Fraud, Waste, Abuse, Program Integrity, FWA, PI, Professional Writing, Verbal Communication, Time Management, Complex Problem Solving/Critical Thinking, Microsoft Excel and Word, Microsoft Access and Outlook
We provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay range for full-time employment is $32.03 - $45.70 hourly. Additional compensation may be available for this role, such as shift differentials, on-call pay, overtime, shift premiums, extra-shift incentives, or bonus opportunities. Compensation within the range may vary based on qualifications, experience, location, market conditions, and business needs.Sentara offers a comprehensive benefits package, including medical, dental, vision, life and disability insurance; 401(k)/403(b) with employer match; paid time off (vacation, sick time, and holidays); paid parental and military leave; educational assistance or student loan repayment; and voluntary benefits.
Benefits: Caring For Your Family and Your Career
• 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
•Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.
Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.
In support of our mission “to improve health every day,” this is a tobacco-free environment.
For positions that are available as remote work,Sentara Health employs associates in the following states:
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, West Virginia, Wisconsin, and Wyoming.
Originally posted on Himalayas