Associate Fraud & Abuse Investigator

Virginia Beach, VA
Sep 26, 2018
Oct 19, 2018
Full Time
Job Description: Responsible for contributing to 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 contributing to the review of the quality of pharmacy, physician, ancillary and hospital based coding in routine desk audits as well as occasional on-site audits. Contribute to the review of reimbursement systems relating to health insurance claims processing and ensures adherence to Optima Health policies and procedures for its various product offerings. Specific progression of responsibility is a follows dependent upon education, certifications, and experience: Triage and prioritize leads/member complaints from internal sources. Review and assess incoming referrals; Assist in the investigation of potential fraud, waste, and abuse. Conduct research in support of an investigation. Collect and evaluate potential suspicious patterns in claims data, provider enrollment data, and other sources and refers to Investigator for investigation or settlement. Assures accurate reimbursement is obtained and coding practices are compliant. Maintain comprehensive case files. Participates in special projects as required.

Keyword: clinical coding

Education Level
Bachelor's Level Degree - Experience in lieu of education: Yes

Required: None, unless noted in the “Other” section below

Preferred: Coding - License
Required: None, unless noted in the “Other” section below

Preferred: Cert Professional Coder


Preferred: None, unless noted in the “Other” section below

Bachelor's Degree in related field required OR Minimum of 2 years combined experience required in Medical Coding OR Healthcare (Medical Chart Review/Insurance Billing) OR Internal/External Audit OR Regulatory/Compliance OR Claims Investigations OR Criminal Investigation/White Collar Crime Certified Professional Coder required (or achieved within 12 months of hire date) Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) preferred. Job skills: Certified Fraud Examiner (CFE) Accredited Health Care Fraud Investigator (AHFI) Professional Writing, Verbal Communication, Time Management Complex Problem Solving/Critical Thinking Microsoft Excel and Word Microsoft Access and Outlook

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