Sentara Health Plan is currently hiring a Senior Fraud and Abuse Investigator/CPC/CFI/CFS/CHC/CFE/AHFI – Remote!

 

Status: Full-time, permanent position (40 hours)

 

Work hours: 8am to 5pm EST, M-F

 

Remote opportunities available 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.

 

Overview

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 at Sentara Health Plans. 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 Optima Health policies and procedures for its various product offerings. Specific progression of responsibility is a follows dependent upon education, certifications, and experience:

Conducts investigation-related training.
Negotiates settlement agreements to resolve disputes.
Maintain current knowledge of relevant laws, regulations and standards.
Updates department policies and procedures and assists in training staff on changes.
Prepares routine department reporting as needed.

 

Education

  • Bachelor's Degree REQUIRED; Degree in a related field of study preferred.

 

Certification/Licensure

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

  • Additional Preferred Qualifications:
    Certified Forensic Interviewer (CFI)
    Certified Fraud Specialist (CFS)
    Certified Professional Coder (CPC) or
    Certified in Healthcare Compliance (CHC)
    Certified Fraud Examiner (CFE) OR Accredited Health Care Fraud Investigator (AHFI) preferred. (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).

 

Experience

  • 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 is strongly 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 www.sentaracareers.com and use the following as your Keyword Search: JR-105160

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), Fraud, Waste, Abuse, Program Integrity, FWA, PI, SIU, Special Investigations Unit, 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) , Bureau of Investigation Training Program (FBITP) – Criminal Investigator Training Program (CITP)

We provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay range for full-time employment is $89,460.80 – $134,139.20 annually. Additional compensation may be available for this role, such as shift differentials, on-call pay, shift premiums, extra-shift incentives, or bonus opportunities. Compensation within the range may vary based on qualifications, experience, location, market conditions, and business needs. Note: If an annual salary is posted, it is based on a full-time colleague working 2,080 hours annually. 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.

Sentara Health, an integrated, not-for-profit health care delivery system, celebrates more than 135 years in pursuit of its mission – “we improve health every day.” Sentara is one of the largest health systems in the U.S. Mid-Atlantic and Southeast, and among the top 20 largest not-for-profit integrated health systems in the country, with 34,000 employees, 12 hospitals in Virginia and Northeastern North Carolina including 10 hospitals with the prestigious Magnet® recognition, and the Sentara Health Plans division which serves more than 1 million members in Virginia and Florida. Sentara is recognized nationally for clinical quality and safety, and is strategically focused on innovation and creating an extraordinary health care experience for our patients and members. Sentara was named a Health Quality Innovator of the Year (2024), was recognized by Forbes as “America’s Best-In-State Employer” (2024), “Best Employer for Veterans” (2022, 2023), and “Best Employer for Women” (2020), and named to IBM Watson Health’s “Top 15 Health Systems” (2021, 2018).

Learn more

A woman smiling as a healthcare worker helps her with arm exercises in a bright, sunlit room.
A woman smiling as a healthcare worker helps her with arm exercises in a bright, sunlit room.
A woman smiling as a healthcare worker helps her with arm exercises in a bright, sunlit room.

Our Culture

At Sentara, our differences are our strengths. The unique backgrounds, skills, and experiences that each Sentara colleague brings to work make Sentara special and allow us to deliver excellent service and care to our patients, members, and communities.

Our Benefits

We are committed to consistently enhancing our training, advancement tracks, work-life benefits, and more. Our goal is to make you feel more excited to be here every day!

Two female doctors in lab coats smiling and chatting in a hospital hallway.
Two female doctors in lab coats smiling and chatting in a hospital hallway.
Two female doctors in lab coats smiling and chatting in a hospital hallway.
Two nurses in scrubs smiling and chatting during a break, one holding a coffee cup in a bright hospital setting.
Two nurses in scrubs smiling and chatting during a break, one holding a coffee cup in a bright hospital setting.

The Sentara Nursing Experience

Making a meaningful impact on health requires compassion, dedication, continuous learning, teamwork and collaboration. At Sentara, we also recognize that in valuing the professional and personal well-being of our nurses, we build a stronger, more supportive workplace for our nurses. And that’s making us healthier from the inside out. These principles unite our nurses across various roles and locations.

Two nurses in scrubs smiling and chatting during a break, one holding a coffee cup in a bright hospital setting.
Surgical assistant in scrubs and mask operates medical monitor in an operating room with other staff in the background.

The Sentara Clinical Experience

No matter where you choose to join us, in an inpatient or outpatient setting, you will be part of an interdisciplinary Clinical team passionate about quality care and patient safety. You will have access to the tools and technologies you need to succeed and the chance to learn and grow through training and educational programs so you can advance your career as a Clinical professional.

Smiling healthcare worker assists a male patient at a clinic front desk while another nurse works in the background.

The Sentara Support Services Experience

Each day, the Sentara Support Services team helps improve healthcare at more than 300 Virginia and Northeastern North Carolina sites. We perform various patient care activities, provide multiple services, and handle administrative functions that support our patients and their families. These vital functions include assisting the medical team in all aspects of medical care, such as treatments, procedures, and diagnostic and laboratory testing.

Smiling medical professionals in scrubs and a lab coat sitting at a table.

The Medical Group Experience

As part of Sentara Health, Sentara Medical Group providers have diverse opportunities across regions and inpatient and outpatient locations. For those providers based in one of 12 hospitals, we have close working relationships with the administration, ensuring a collegial and collaborative environment where all can come together around shared initiatives.

Guided by a dedicated board of providers, Sentara Medical Group not only offers leadership opportunities for its providers but also underscores the group’s crucial role in fulfilling Sentara’s overarching mission to meet the needs of our diverse patient populations, some of our most vulnerable communities. Our physicians and APPs enjoy opportunities for both personal and professional career growth through a network of resources aimed to cultivate an environment suitable for a lifelong career home.

Your Perspective Matters

Nurses are the heartbeat of our exceptional team. Our approach empowers nurses to actively participate in decision-making. Our nurses have a stake in shaping their workplace as well as their own career growth; one of the benefits of our focus on supporting and valuing team members. This framework encompasses our nursing mission, vision, values, philosophy, and the essential elements of our Professional Practice Model.

This image illustrates the Sentara Nursing Professional Practice Model. Read more about it on The Sentara Nurse Experience page.

Visual representation of the Sentara Nursing Professional Practice Model.

We Are an Equal Opportunity Employer

Sentara Health is an Equal Opportunity Employer committed to the hiring, advancement, and fair treatment of every individual. Sentara and its affiliates do not discriminate against any individual or group of individuals on the basis of race, color, religion, ancestry, national origin, marital status, age, sex, sexual orientation, gender identity or expression, genetic information, physical or mental disability, pregnancy, medical condition, veteran status or any other legally protected characteristics.

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    We Are an Equal Opportunity Employer

    Sentara Health is an Equal Opportunity Employer committed to the hiring, advancement, and fair treatment of every individual. Sentara and its affiliates do not discriminate against any individual or group of individuals on the basis of race, color, religion, ancestry, national origin, marital status, age, sex, sexual orientation, gender identity or expression, genetic information, physical or mental disability, pregnancy, medical condition, veteran status or any other legally protected characteristics.

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