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

Sentara Health; Maine; Remote; USD 44,000 - 63,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

401k/403B with Employer Match

Paid Time Off and Holidays

Tuition Assistance

Job summary

Sentara Health Plans is hiring an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) for a remote role. The position is full-time with standard hours and travel to Virginia Beach once a year.

Remote eligibility includes ME and many other states; occasional on-site travel to Virginia Beach is required. The role involves investigations of fraud, coding reviews, and ensuring compliant reimbursement, with a strong emphasis on documentation and data analysis.

Qualifications

• Bachelor's degree required.
• 2+ years combined experience in medical coding, healthcare, audits, compliance, or investigations required.

Responsibilities

• Contribute to in-depth investigations of suspected fraud or abuse across provider, pharmacy, employer, member, and broker interactions.
• Review coding quality in routine desk audits and on-site audits.
• Assess reimbursement systems and ensure policy compliance.
• Triages leads and assists in investigations of potential fraud, waste, or abuse.
• Maintain comprehensive case files and participate in special projects.

Skills

Professional Writing

Verbal Communication

Time Management

Critical Thinking

Excel

Word

Access

Outlook

Education

Bachelor's Degree

2+ years combined experience in Medical Coding/Healthcare/Audit/Compliance/Investigations

Tools

Microsoft Excel

Microsoft Word

Microsoft Access

Outlook

Job description

City/State Norfolk, VA

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)

Work hours 8am to 5pm EST, M-F

Location This position is remote for candidates that live in the following states: VA, NC, AL, DE, FL, GA, ID, IN, KS, LA, ME, MD, MN, NE, NV, NH, ND, OH, OK, PA, SC, SD, TN, TX, UT, WA, WV, WI, WY! With travel to Virginia Beach 1x a year.

Job Responsibilities

• 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.
• 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.

Education

• Bachelor's Degree 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 REQUIRED

Certifications/Licenses

• Certified Professional Coder (CPC) REQUIRED (or achieved within 12 months of hire date)
• Certified Fraud Examiner (CFE) OR Accredited Health Care Fraud Investigator (AHFI) preferred.

Experience

• Job skills: 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!

We provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. 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. Compensation within the range may vary based on qualifications, experience, location, market conditions, and business needs. Sentara offers a comprehensive benefits package, including medical, dental, vision, life and disability insurance; 401(k)/403(b) with employer match; paid time off (vacation, sick time, and holidays); paid parental and military leave; educational assistance or student loan repayment; and voluntary benefits.

Benefits: Caring For Your Family and Your Career

• Medical, Dental, Vision plans
• Adoption, Fertility and Surrogacy Reimbursement up to $10,000
• Paid Time Off and Sick Leave
• Paid Parental & Family Caregiver Leave
• Emergency Backup Care
• Long-Term, Short-Term Disability, and Critical Illness plans
• Life Insurance
• 401k/403B with Employer Match
• Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education
• Student Debt Pay Down – $10,000
• Pet Insurance
• Legal Resources Plan
• Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.

Sentara Health is an equal opportunity employer 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:

Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.