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

Sentara; Virginia (MN); Remote; USD 60,000 - 100,000; Full time

Job summary

Join a forward-thinking healthcare organization as a Fraud and Abuse Investigator. This full-time remote role involves investigating potential fraud and ensuring compliance across various healthcare product lines. With a focus on quality and integrity, you will play a crucial role in safeguarding the health of nearly one million members. The ideal candidate will have a Bachelor's Degree and experience in medical coding or auditing. If you're passionate about making a difference in healthcare and thrive in a collaborative environment, this is the perfect opportunity for you.

Qualifications

• Bachelor's Degree required; related field preferred.
• Minimum 2 years experience in Medical Coding or Healthcare Auditing.

Responsibilities

• Contribute to investigations of suspected fraud or abuse.
• Review coding during audits and ensure compliance.
• Analyze findings and assist in settlements.

Skills

Medical Coding

Healthcare Auditing

Claims Investigations

Fraud Analysis

Education

Bachelor's Degree

Job description

City/State

Norfolk, VA

Work Shift

First (Days)

Overview:

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: Remote for candidates in 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 annual travel to Virginia Beach.

Job Responsibilities:

• Contribute to investigations of suspected fraud or abuse involving providers, pharmacies, employers, members, and brokers across all product lines.
• Review pharmacy, physician, ancillary, and hospital coding during desk audits and on-site visits.
• Assess reimbursement systems for health insurance claims and ensure compliance with policies.
• Depending on experience, responsibilities include identifying, investigating, analyzing potential fraud, conducting interviews, analyzing findings, and assisting in settlements.

Education:

• Bachelor's Degree REQUIRED; related field preferred.
• Minimum 2 years experience in Medical Coding, Healthcare, Auditing, Compliance, Claims Investigations, or Criminal Investigation.

Certifications/Licenses:

• Certified Professional Coder (CPC) REQUIRED or achieved within 12 months of hire.
• Preferred: CFE, AHFI, CFI, CFS, CHC, or FBI Criminal Investigator training.

Sentara Health Plans serves nearly one million members in Virginia with diverse health products and a robust provider network. We support members with chronic illnesses through various programs and foster a family-friendly, community-oriented culture.

Join us to improve health every day, focusing on quality, safety, service, and integrity. Apply at www.sentaracareers.com using Keyword: JR-77544.