FRAUD & ABUSE INVESTIGATOR

Location
Virginia Beach, VA
Posted
Mar 16, 2017
Closes
Jun 01, 2017
Function
Nurse
Industry
Healthcare
Hours
Full Time
Job Description: Responsible for conducting in-depth investigations for suspected fraud or abuse with respect to provider, pharmacy, employer, member, and broker interactions involving the full range of products at Optima Health. Responsible for reviewing the quality of pharmacy, physician, ancillary and hospital based coding in routine desk audits as well as occasional on-site audits. Reviews reimbursement systems relating to health insurance claims processing and ensures adherence to Optima Health policies and procedures for its various product offerings.

Education Level
Bachelor's Level Degree

Experience
Required: Related - 3 years

Preferred: Insurance - 3 years

License
None, unless noted in the “Other” section below

Skills
Required: Coding, Complex Problem Solving, Critical Thinking, Microsoft Excel, Microsoft Office, Speaking, Time Management, Writing

Preferred: Microsoft Access

Other
Related experience includes: Coding 3 years OR Healthcare (Medical Chart Review/Insurance Billing) - 3 years OR Internal/External Audit - 3 years OR Regulatory/Compliance - 3 years OR Claims Investigations 3 years OR Criminal Investigation/White Collar Crime 3 years. Certified Professional Coder required (or achieved within 12 months of hire date). Certified Fraud Examiner (CFE) preferred or Accredited Health Care Fraud Investigator (AHFI) preferred.