Manager, Special Investigative Unit/ Program Integrity/ CPC - Remote

Sentara Health Plans; Norfolk, Northern (VA, KY); Hybrid; USD 79,000 - 132,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

401k/403B with Employer Match

Paid Time Off

Tuition Assistance

Annual bonus opportunities

Job summary

Sentara Health Plans in Norfolk, VA, is seeking a Manager for the Special Investigative Unit/Program Integrity (CPC) role, supporting remote work across several states. You will lead a multi-state SIU team and coordinate with providers and government agencies.

The position requires a Bachelor's degree, CPC certification, and 5 years of coding experience with 2 years in supervision, plus strong alignment to fraud, waste and abuse controls.

Qualifications

• Bachelor’s degree REQUIRED
• 2 years of Supervisory experience REQUIRED
• 5 years of Coding experience REQUIRED
• Insurance experience REQUIRED
• CPC certification REQUIRED
• Experience leading pre-payment reviews and payment integrity in a healthcare payer environment REQUIRED

Responsibilities

• Manage a SIU team across multiple states and report findings to government/regulatory agencies.
• Interact with internal departments, providers and government agencies.
• Review/update health plan rules related to fraud, waste and abuse.
• Provide compliance advice and assist with organizational change and interpretation.
• Lead the monthly FWA subcommittee meeting.

Skills

Supervisory experience

Healthcare payer experience

Coding knowledge

Regulatory reporting

Education

Bachelor's degree

Job description

Manager, Special Investigative Unit/ Program Integrity / CPC - Remote

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 travel to 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.

Company Overview

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 rate for Full Time employment is: $38.22/hour- $63.70/hour. Additional compensation may be available for this role such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.

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
• 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 if established system and employee eligibility criteria is met.

Equal Opportunity Employer

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.

Remote Work

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.

Servicing Communities

Sentara Health is a Virginia and Northeastern North Carolina based not-for-profit integrated healthcare provider that has been in business for over 131 years. Offering hundreds of sites of care including 12 hospitals, PACE, home health, hospice, medical groups, imaging services, therapy, outpatient surgery centers, and an 858,000 member health plan. The people of the communities that we serve have nominated Sentara “Employer of Choice” for over ten years. U.S. News and World Report has recognized Sentara as having the Best Hospitals for 15+ years. Sentara offers professional development and a continued employment philosophy!