Associate Fraud and Abuse Investigator/CPC- Remote

Sentara Health Plans; Alabama; Remote; USD 60,000 - 80,000; Full time

Job summary

An established industry player is seeking an Associate Fraud and Abuse Investigator for a remote position. This role involves in-depth investigations into suspected fraud and abuse, ensuring compliance with healthcare coding and reimbursement practices. You will play a crucial role in maintaining the integrity of health insurance claims processing while contributing to special projects. This position offers the opportunity to work within a diverse and inclusive environment, dedicated to supporting members with comprehensive health services. If you have a passion for problem-solving and a background in healthcare investigations, this is the perfect opportunity for you.

Qualifications

• 2+ years experience in Medical Coding, Healthcare, or Investigations required.
• CPC certification required within 12 months of hire.

Responsibilities

• Conduct investigations for suspected fraud or abuse in healthcare.
• Review coding practices and ensure compliance with policies.
• Maintain comprehensive case files and participate in special projects.

Skills

Professional Writing

Verbal Communication

Time Management

Complex Problem Solving

Critical Thinking

Microsoft Excel

Microsoft Word

Microsoft Access

Microsoft Outlook

Education

Bachelor's Degree

Job description

Associate Fraud and Abuse Investigator/CPC- Remote!

Associate Fraud and Abuse Investigator/CPC- Remote!

Location: 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).

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

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

Overview:

Sentara Health Plan is currently hiring an Associate Fraud and Abuse Investigator/CPC- Remote!

Job Responsibilities:

• Contribute to in-depth investigations for suspected fraud or abuse with respect to provider, pharmacy, employer, member, and broker interactions.
• Review the quality of pharmacy, physician, ancillary and hospital-based coding in routine desk audits and occasional on-site audits.
• Review reimbursement systems relating to health insurance claims processing and ensure adherence to policies and procedures.
• 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 and other sources.
• Assure accurate reimbursement is obtained and coding practices are compliant.
• Maintain comprehensive case files.
• Participate in special projects as required.

Education:

• Bachelor's Degree REQUIRED
• Minimum of 2 years combined experience 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.

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.

To apply, please go to www.sentaracareers.com and use the following as your Keyword Search: JR-77536

Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its workforce.