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

Sentara Health; Virginia; Hybrid; USD 109,000 - 163,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

401k/403B with Employer Match

Paid Time Off and Holidays

Educational assistance or student loan

Job summary

Sentara Health Plans seeks a senior leader to manage a multi-state SIU team and report findings to appropriate government agencies. The role requires extensive collaboration with internal departments, providers, and regulatory bodies to refine health plan fraud, waste, and abuse policies while guiding organizational change and compliance interpretation.

With a base focus on Virginia health plans, the position includes remote opportunities across numerous states, occasional travel to Virginia

Qualifications

• Bachelor’s degree required.
• CPC certification required.
• 2 years of supervisory experience.
• 5 years of coding experience.
• Insurance experience preferred.

Responsibilities

• Manage a team of SIU Investigators across multiple states.
• Report findings to government and regulatory agencies.
• Interact with internal departments, providers and government agencies.
• Review and propose updates to health plan rules related to fraud, waste and abuse.
• Provide compliance advice and assist with organizational change and interpretation of compliance.

Skills

Supervisory experience

Insurance experience

Coding experience

Education

Bachelor’s degree

CPC certification

Job description

City/State Norfolk, VA. Work Shift: Multiple shifts available.

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.
• 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.

Education

• Bachelor’s degree REQUIRED

Certifications/Licenses

• Certified Professional Coder (CPC) REQUIRED

Experience

• 2 years of Supervisory experience
• Insurance experience
• 5 years of Coding experience

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!

Sentara provides 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

• 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.

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.

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!