Investigations Manager

Sentara Health; Alaska; A distancia; USD 109.000 - 163.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical, dental, vision plans

Paid time off & holidays

401(k) with employer match

Educational assistance

Descripción de la vacante

Sentara Health Plans is seeking a Manager for the Special Investigative Unit/ Program Integrity with CPC certification to oversee multi-state investigations remotely. The role is full-time with a 40-hour workweek and requires strong leadership in fraud, waste and abuse program governance.

Responsibilities include guiding compliance, coordinating with internal teams, and presenting findings to regulatory bodies.

Formación

• Bachelor's degree required.
• CPC certification required.
• At least 2 years of supervisory experience.
• 5 years of coding experience in healthcare payer environments.
• Leadership experience in pre-pay review and provider monitoring.

Responsabilidades

• Lead a multi-state SIU team of investigators.
• Report findings to government and regulatory agencies.
• Interact with internal departments, providers and agencies.
• Review and update health plan rules related to FWA.
• Provide compliance guidance for organizational changes.
• Lead the monthly FWA subcommittee meeting.

Conocimientos

Team leadership

Supervisory experience

Fraud, waste and abuse knowledge

Educación

Bachelor's degree

CPC certification

Descripción del empleo

City/State

Norfolk, VA

Work Shift

Multiple shifts available

Overview:

Sentara Health Plan is currently hiring a Manager, Special Investigative Unit/ Program Integrity / CPC - 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 travelto Virginia Beach 1x a year.

Job Responsibilities:

• Position is responsible for managing a team of Special Investigative Unit (SIU) Investigators across multiple states.
  
• Is also responsible for reporting findings to appropriate government and regulatory agencies.
  
• Position requires extensive interaction with various internal departments as well as providers and government agencies.
  
• Responsible for reviewing and proposing updates to health plan rules and policies as they relate to fraud, waste and abuse.
  
• Provides compliance advice and assists with organizational change and compliance interpretation as it relates to fraud, waste and abuse.
  
• Leads the monthly FWA subcommittee meeting.
  

Education:

• Bachelor's degree REQUIRED
  

Certifications/Licenses:

• Certified Professional Coder (CPC) REQUIRED
  

Experience:

• 2 years of Supervisory experience REQUIRED
  
• Insurance experience REQUIRED
  
• 5 years of Coding experience REQUIRED
  
• Candidates must have prior leadership experience managing a pre-pay review team, including oversight of pre-payment claim reviews, provider monitoring activities, medical record reviews, and payment integrity operations within a healthcare payer environment.
  

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!

We provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay range for full-time employment is $109,033.60 - $163,259.20 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.

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

Know Worker Rights

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 ifestablished 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.