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

Sentara Health; Richmond (VA); Remote; USD 109,000 - 163,000; Full time

Benefits offered by this job

Medical, Dental, Vision

401(k) match

Paid Time Off

Job summary

Sentara Health Plan is seeking a Manager, Special Investigative Unit/Program Integrity to lead a nationwide SIU team. This remote role supports fraud, waste, and abuse investigations and requires collaboration with internal teams and external agencies.

Applicants should have CPC certification, a Bachelor’s degree, and at least 2 years of supervisory experience in a healthcare payer setting, with 5 years of coding and prior pre-pay review leadership.

Qualifications

• Bachelor’s degree is required for this role.
• CPC certification is required.
• Minimum 2 years of supervisory experience.
• Insurance industry experience required.
• Minimum 5 years of coding experience and leadership in pre-pay review.

Responsibilities

• Manage SIU investigators across multiple states.
• Report findings to government and regulatory agencies.
• Review and update health plan rules related to FWA.
• Provide compliance guidance and interpret changes for the team.
• Lead the monthly FWA subcommittee meeting.

Skills

Supervisory experience

Healthcare payer experience

Regulatory and compliance knowledge

Leadership and team management

Education

Bachelor’s degree

Certified Professional Coder (CPC)

Job description

City/StateNorfolk, VAWork ShiftMultiple shifts availableOverview: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-FRemote 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 REQUIREDCertifications/Licenses:Certified Professional Coder (CPC) REQUIREDExperience:2 years of Supervisory experience REQUIREDInsurance experience REQUIRED5 years of Coding experience REQUIREDCandidates 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!To apply, please go to www.sentaracareers.com and use the following as your Keyword Search: JR-102996#LI-PM1Talroo-Health PlanKeywords: 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, ManagerWe 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• 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.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.