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

Sentara Healthcare Inc; Norfolk (VA); Remote; USD 60,000 - 80,000; Full time

Job summary

Sentara Health Plan is seeking a full-time Fraud and Abuse Investigator/CPC for a remote role, requiring at least 2 years of experience in medical coding or healthcare investigation. This position involves conducting thorough investigations into suspected fraud, ensuring compliance with healthcare regulations, and making recommendations based on detailed analyses. Join a reputable organization committed to improving health and community engagement.

Qualifications

• Minimum of 2 years combined experience in Medical Coding, Healthcare Compliance, or Fraud Investigation.
• Certified Professional Coder (CPC) is required within 12 months of hire.
• Preferred: Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI).

Responsibilities

• Conduct in-depth investigations of suspected fraud or abuse.
• Review pharmacy, physician, and hospital coding during audits.
• Analyze health insurance claims processing for adherence to policies.

Skills

Investigation

Medical Coding

Compliance

Analysis

Education

Bachelor's Degree

Certified Professional Coder (CPC)

Certified Fraud Examiner (CFE)

Job description

Sentara Health Plan is currently hiring a Fraud and Abuse Investigator/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 travelto 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:

- Identify, investigate, analyze and evaluate instances of potential fraud, waste and abuse.
- Conduct interviews or correspond with patients, providers, witnesses or other relevant parties to determine settlement, denial or review.
- Analyze information gathered by investigation and report findings and recommendations as a written summary and/or presentation
- Learn and conduct statistical sampling of complex medical claims
Assists in drafting settlements

Education:

• 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

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. (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)

• Certified Forensic Interviewer (CFI), Certified Fraud Specialist (CFS), Certified Professional Coder (CPC) or Certified in Healthcare Compliance (CHC) preferred

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!

To apply, please go towww.sentaracareers.comand use the following as your Keyword Search:JR-77544

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#Indeed

Talroo-Health Plan

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