Norfolk, Virginia
Fraud & Abuse Investigator Job Opening in Norfolk, Virginia - WHERE VIRGINIANS CARE FOR VIRGINIANS
Careers in Care
As a nationally recognized provider of health plan coverage and innovative wellness programs, we live our mission to ?improve health every day.? Optima Health Community Care is our latest offering ? a new Medicaid option for older people and those with disabilities. Working in partnership with the Virginia Department of Medical Assistance Services we will be managing long-term services and providing support to Virginians with complex health issues.
Fraud & Abuse Investigator
Responsible for conducting 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 Optima Health. Responsible for reviewing the quality of pharmacy, physician, ancillary and hospital based coding in routine desk audits as well as occasional on-site audits. Reviews reimbursement systems relating to health insurance claims processing and ensures adherence to Optima Health policies and procedures for its various product offerings.
Qualifications:
Education:
Bachelor's Degree
Job Experience:
3 years of experience in one or more of the following:
Coding (Certified Professional Coder required (or achieved within 12 months of hire date))
Healthcare (Medical Chart Review/Insurance Billing)
Internal/External Audit
Claims Investigations
Criminal Collar Crime
Must have one or more of the following certifications:
Accredited Health Care Fraud Investigator (AHFI)
Certified Fraud Examiner (CFE)
Certified in Healthcare Compliance (CHC) or other specialty coding certification
Certificate for OASIS Specialist-Clinical (COS-C)
Certificate for Home Care Coding (HCS-D)
Regulatory Affairs Certification (RAC)
Certified Insurance Fraud Investigator (CIFI)
Certified Insurance Fraud Analyst (CIFA)
Registered Health Information Technician (RHIT)
Certified Medical Audit Specialist (CMAS)
Additional Skills:
Complex Problem Solving
Critical Thinking
Microsoft Excel and Office
Time Management
Microsoft Access (Preferred)
*Must currently reside in Virginia or be willing to relocate to Norfolk, VA area
Job Type: Full-time
Required education:
Bachelor's
Required experience:
ICD-9 or ICD-10: 1 year
healthcare investigative: 1 year
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