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.

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.

To apply, please go to www.sentaracareers.com and use the following as your Keyword Search: JR-102996

Talroo-Health Plan

Keywords: 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, Manager