Principal Fraud & Abuse Investigator

Company: Sentara Health
Location: Tallahassee
Posted on: February 20, 2025

Job Description:

City/State
Tallahassee, FL

Overview

Work Shift
First (Days) (United States of America)

AvMed, a division of Sentara Health Plans in the Florida market, is hiring a Remote Principal Fraud & Abuse Investigator.

The Remote Principal Fraud & Abuse Investigator is 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 in 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 Contribute 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. Specific progression of responsibility is a follows dependent upon education, certifications, and experience. Assist manager in development and conducting division wide Fraud, Waste and Abuse related training. Develops and updates department policies and procedures and trains staff as needed. Develops and prepares departmental reporting for internal and external use. Assist manager in implantation and compliance with of state and federal program integrity activities and reporting requirements. Supports legal proceedings as needed, including testifying in court or working with law enforcement personnel to prepare cases for civil or criminal actions. Assists in training and provides guidance to staff.

Remote opportunities available 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 (state), West Virginia, Wisconsin, Wyoming

Requirements:
--- Bachelor's Degree in related discipline required.
--- 8-10 years of related investigative experience OR 5-7 years of related healthcare investigative experience AND CFE OR AHFI
--- Certified Professional Coder required (or achieved within 12 months of hire date) AND Accredited Health Care Fraud Investigator (AHFI) required (or achieved within 24 months of date of hire)
--- (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)
--- 5 years of Coding, Healthcare, Internal/External Audits & Regulatory Compliance.

Preferred Qualifications:
--- Certified Fraud Specialist (CFS),
--- Certified Professional Coder (CPC)
--- Certified Forensic Interviewer (CFI)
Certified in Healthcare Compliance (CHC)hen 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 in 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 Contribute 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. Specific progression of responsibility is a follows dependent upon education, certifications, and experience. Assist manager in development and conducting division wide Fraud, Waste and Abuse related training. Develops and updates department policies and procedures and trains staff as needed. Develops and prepares departmental reporting for internal and external use. Assist manager in implantation and compliance with of state and federal program integrity activities and reporting requirements. Supports legal proceedings as needed, including testifying in court or working with law enforcement personnel to prepare cases for civil or criminal actions. Assists in training and provides guidance to staff.

Our Benefits:

As the third-largest employer in Virginia, Sentara Health was named by Forbes Magazine as one of America's best large employers. We offer a variety of amenities to our employees, including, but not limited to:

--- Medical, Dental, and Vision Insurance
--- Paid Annual Leave, Sick Leave
--- Flexible Spending Accounts
--- Retirement funds with matching contribution
--- Supplemental insurance policies, including legal, Life Insurance and AD&D among others
--- Work Perks program including discounted movie and theme park tickets among other great deals
--- Opportunities for further advancement within our organization

Sentara employees strive to make our communities healthier places to live. We are setting the standard for medical excellence within a vibrant, creative, and highly productive workplace. For information about our employee benefits, please visit: Benefits - Sentara ()

Sentara Health offers employees comprehensive health care and retirement benefits designed with you and your family's well-being in mind. Our benefits packages are designed to change with you by meeting your needs now and anticipating what comes next. You have a variety of options for medical, dental and vision insurance, life insurance, disability and voluntary benefits as well as Paid Time Off in the form of sick time, vacation time and paid parental leave. Team Members have the opportunity to earn an annual flat amount Bonus payment if established system and employee eligibility criteria is met.

For applicants within Washington and Maryland State, the following hiring range will be applied: $72,421.44 annually to $ 99,896.16 annually

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 in 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 Contribute 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. Specific progression of responsibility is a follows dependent upon education, certifications, and experience. Assist manager in development and conducting division wide Fraud, Waste and Abuse related training. Develops and updates department policies and procedures and trains staff as needed. Develops and prepares departmental reporting for internal and external use. Assist manager in implantation and compliance with of state and federal program integrity activities and reporting requirements. Supports legal proceedings as needed, including testifying in court or working with law enforcement personnel to prepare cases for civil or criminal actions. Assists in training and provides guidance to staff.

Bachelor's Degree in related discipline required.
8-10 years of related investigative experience OR 5-7 years of related healthcare investigative experience AND CFE OR AHFI

Certified Professional Coder required (or achieved within 12 months of hire date) AND Accredited Health Care Fraud Investigator (AHFI) required (or achieved within 24 months of date of hire)

(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)

Preferred Qualifications:
1. Certified Fraud Specialist (CFS),
2. Certified Professional Coder (CPC)
3. Certified Forensic Interviewer (CFI), or
4. Certified in Healthcare Compliance (CHC)

Qualifications:

BLD - Bachelor's Level Degree (Required)

Certified Professional Coder (CPC) - Certification - American Academy of Professional Coders (AAPC)

Coding, Healthcare, Internal/External Audit, Regulatory/Compliance

Skills

Communication, Complex Problem Solving, Critical Thinking, Microsoft Access, Microsoft Excel, Microsoft Word, Time Management, Writing

Sentara Healthcare 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.

Per Clinical Laboratory Improvement Amendments (CLIA), some clinical environments require proof of education; these regulations are posted at ecfr.gov for further information. In an effort to expedite this verification requirement, we encourage you to upload your diploma or transcript at time of application.

In support of our mission "to improve health every day," this is a tobacco-free environment.

Keywords: Sentara Health, Tallahassee , Principal Fraud & Abuse Investigator, Other , Tallahassee, Florida