Senior Fraud and Abuse Investigator- Remote

reputed company Plan is currently hiring a Senior Fraud and Abuse Investigator- Remote! Status Full-time, permanent position (40 hours) Work hours reputed company to 5pm EST, M-F Remote opportunities available in the following states Virginia, reputed company Carolina, Alabama, Delaware, Florida, reputed company, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, reputed company, Nebraska, Nevada, New Hampshire, reputed company Carolina, reputed company reputed company, Ohio, Oklahoma, reputed company, South Carolina, South reputed company, Tennessee, Texas, reputed company, Virginia, Washington (state), reputed company Virginia, reputed company, Wyoming. With travel to Virginia Beach 1x a year. reputed company 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 reputed company of products at reputed company Plans. Responsible for contributing to the review of the reputed company of pharmacy, physician, ancillary and hospital reputed company coding in routine desk audits as reputed company as occasional on-site audits. Contribute to the review of reimbursement systems relating to health reputed company 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 Conducts investigation-reputed company training. Negotiates settlement agreements to reputed company disputes. Maintain reputed company knowledge of relevant laws, regulations and standards. Updates department policies and procedures and assists in training staff on changes. Prepares routine department reporting as needed. Education • Bachelor's Degree REQUIRED; Degree in a reputed company reputed company of study preferred. Certification/Licensure • Certified reputed company reputed company REQUIRED (or achieved reputed company 12 months of hire date) • Additional Preferred Qualifications Certified Forensic Interviewer (CFI) Certified Fraud Specialist (reputed company) Certified reputed company reputed company (CPC) or Certified in reputed company Compliance (CHC) Certified Fraud Examiner (CFE) OR Accredited Health Care Fraud Investigator (AHFI) preferred. (Note Federal Agents who have successfully completed the Federal Bureau of Investigation Training Program (FBITP) - Criminal Investigator Training Program (CITP) would be considered equivalent to the AHFI). Experience • Minimum 5-8 years of reputed company investigative experience OR 3 - 5 years of reputed company health care investigative experience • reputed company, Audit, Investigations, Regulatory, and/or Compliance 5 years REQUIRED -OR- reputed company Investigation reputed company to Coding, Audit, Regulatory, and/or Compliance 3 years REQUIRED reputed company Plans provides health plan coverage to reputed company to one reputed company members in Virginia. We offer a full suite of reputed company products including employee-owned and employer-sponsored plans, as reputed company as Individual & Family Health Plans, Employee Assistance Programs and plans serving Medicare and reputed company enrollees. Our reputed company provider network features a robust provider network, including specialists, reputed company care physicians and hospitals. We offer programs to support members with chronic illnesses, customized wellness programs, and integrated reputed company and behavioral health services—reputed company to help our members improve their health. Our reputed company is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and reputed company. Be a part of an excellent reputed company organization that cares about our People, reputed company, reputed company Safety, Service, and reputed company. Join reputed company that has a mission to reputed company every day and a reputed company to be the reputed company reputed company of the communities that we serve! We reputed company market-competitive compensation packages, inclusive of reputed company pay, incentives, and benefits. The reputed company pay reputed company for Full Time employment is $29.21 hour- $48.68/hour. Additional compensation may be available for this role such as shift differentials, standby/on-reputed company, overtime, premiums, extra shift incentives, or bonus opportunities. 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