Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) -Remote!

Sentara Health; Crystal Bay (NV); Remote; USD 44,000 - 63,000; Full time

Benefits offered by this job

Adoption & surrogacy benefit

Disability & critical illness

Life Insurance

Legal Resources Plan

Annual discretionary bonus

Job summary

Sentara Health Plans in the United States is hiring an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) for a remote role. The position is full-time (40 hours) with occasional travel to Virginia Beach.

You will contribute to deep investigations of fraud across provider, pharmacy, and claims, review coding quality, and help ensure accurate reimbursement. Remote work is available for qualified US candidates, with annual travel to Virginia Beach.

Qualifications

• Bachelor's Degree required.
• Minimum 2 years combined experience in Medical Coding or Healthcare/audit related fields.
• CFE or AHFI certification preferred.

Responsibilities

• Assist in investigations of potential fraud, waste and abuse.
• Review coding quality for pharmacy, physician, and hospital services.
• Triage and prioritize leads from internal sources.
• Research data patterns in claims and provider data to support investigations.
• Contribute to special projects as required.

Skills

Professional Writing

Verbal Communication

Time Management

Complex Problem Solving

Critical Thinking

Education

Bachelor's Degree

Tools

Microsoft Excel

Microsoft Word

Microsoft Access

Outlook

Job description

Work Shift

Multiple shifts available

Sentara Health Plan is currently hiring an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) Remote!

Status: Full-time, permanent position (40 hours)

Location: This position is remote for candidates that live in the following states: With travel to Virginia Beach 1x a year.

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.

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 policies and procedures for its various product offerings.

Triage and prioritize leads/member complaints from internal sources.

• 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.
• Participates in special projects as required.

Bachelor's Degree

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 Fraud Examiner (CFE) OR 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

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!

The base pay range for full-time employment is $32.03 - $45.70 hourly. Additional compensation may be available for this role, such as shift differentials, on-call pay, overtime, shift premiums, extra-shift incentives, or bonus opportunities. Sentara offers a comprehensive benefits package, including medical, dental, vision, life and disability insurance; paid time off (vacation, sick time, and holidays); Medical, Dental, Vision plans

• Adoption, Fertility and Surrogacy Reimbursement up to $10,000
• Long-Term, Short-Term Disability, and Critical Illness plans
• Life Insurance
• Legal Resources Plan
• Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.

and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

In support of our mission “to improve health every day,” this is a tobacco‑free environment.

For positions that are available as remote work, Sentara Health employs associates in the following states: