Associate Fraud and Abuse Investigator/Certified Professional reputed company (CPC) - Remote

reputed company Plan is currently hiring an Associate Fraud and Abuse Investigator/Certified Professional reputed company (CPC) Remote! Status: Full-time, permanent position (40 hours) Work hours: reputed company 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 reputed company (CPC) REQUIRED (or achieved reputed company 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, reputed company Problem Solving/Critical Thinking, reputed company reputed company and Word, reputed company Access and Outlook

reputed company Plans provides health plan coverage to reputed company 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—reputed company 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 reputed company. 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-77536 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), reputed company 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 reputed company (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 (reputed company), Certified Professional reputed company (CPC) or Certified in Healthcare Compliance (CHC), Fraud, Waste, Abuse, Program reputed company, FWA, PI, Professional Writing, Verbal Communication, Time Management, reputed company Problem Solving/Critical Thinking, reputed company reputed company and Word, reputed company Access and Outlook Apply Job! Apply To This Job