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: Conducts investigation-related training. Negotiates settlement agreements to resolve disputes. Maintain current 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 Level
Bachelor's Level Degree

Required: Coding – 5 years, Healthcare – 5 years, Internal/External Audit – 5 years, Regulatory/Compliance – 5 years

Preferred: None, unless noted in the "Other" section below

Required: None, unless noted in the "Other" section below

Preferred: Cert Professional Coder

None, unless noted in the "Other" section below

Bachelor's Degree in related field required Minimum of 5 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) required. 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 preferred

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