Fraud and Abuse Investigator / CPC - Remote

170 Sentara Health Administration, Inc.; Virginia; Hybrid; USD 73,000 - 110,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

401k/403B with employer match

Paid Time Off & Holidays

Educational assistance

Job summary

Sentara Health Plans is seeking a Fraud and Abuse Investigator with CPC certification for a remote, full-time role in the Virginia area. Work hours are 8am–5pm EST, Monday–Friday, with travel to Virginia Beach once yearly.

The ideal candidate will investigate potential fraud, perform data-driven claim analyses, and contribute to on-site audits as needed, ensuring adherence to health plan policies and procedures across Sentara Health Plans’ product lines.

Qualifications

• 2 years combined experience in Internal/External Audit or regulatory/compliance or healthcare preferred.
• Familiarity with healthcare claims, provider billing patterns, fraud, waste and abuse (FWA) concepts.
• Experience reviewing claims and using data analysis to identify review-needed items.

Responsibilities

• Identify, investigate, analyze, and evaluate instances of potential fraud, waste, and abuse.
• Conduct interviews or correspondence with patients, providers, witnesses, or other relevant parties to determine settlement, denial, or review.
• Analyze information gathered by investigation and report findings and recommendations in writing or presentation.
• Learn and conduct statistical sampling of complex medical claims.
• Assist in drafting settlements.

Skills

Fraud and Abuse Investigations

Certified Professional coder CPC

Data analysis

Claims review

Regulatory/compliance

Education

Bachelor's degree preferred

Job description

Location

City/State Norfolk, VA

Work Shift

First (Days)

Overview

Sentara Health Plan is currently hiring a Fraud and Abuse Investigator/Certified Professional Coder (CPC) Remote! Status: Full-time, permanent position (40 hours) Work hours: 8am to 5pm EST, M-F

Remote Eligibility

This position is remote for candidates that live in the following states: Virginia, North Carolina, 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 (state), West Virginia, Wisconsin, Wyoming; With travel to Virginia Beach 1x a year.

Job Summary

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 through Sentara Health Plans lines of business. 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. Contributes to the review of reimbursement systems relating to health insurance claims processing and ensures adherence to health plan policies and procedures for its various product offerings.

Job Description

• 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

Bachelor's degree preferred

Certifications/Licenses

Certified Professional Coder preferred (or achieved within 12 months of hire date)

Experience

2 years combined experience required in Internal/External Audit OR regulatory/Compliance OR Healthcare preferred Experience reviewing claims, analyzing data, identifying potential billing irregularities, and supporting pre-pay review activities. Familiarity with healthcare claims, provider billing patterns, fraud, waste and abuse (FWA) concepts, and the use of data analysis to identify claims or providers requiring further review is preferred.

About Sentara Health Plans

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 everyday and a vision to be the healthcare choice of the communities that we serve!

Compensation

We provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay range for full-time employment is $72,612.80 - $109,990.40 annually. Additional compensation may be available for this role, such as shift differentials, on-call pay, shift premiums, extra-shift incentives, or bonus opportunities. Compensation within the range may vary based on qualifications, experience, location, market conditions, and business needs. If an annual salary is posted, it is based on a full-time colleague working 2,080 hours annually.

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

Equal Opportunity and Diversity

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.

Additional Information

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.

Sentara Health is a Virginia and Northeastern North Carolina based not-for-profit integrated healthcare provider that has been in business for over 131 years. Offering hundreds of sites of care including 12 hospitals, PACE, home health, hospice, medical groups, imaging services, therapy, outpatient surgery centers, and an 858,000 member health plan. The people of the communities that we serve have nominated Sentara “Employer of Choice” for over ten years. U.S. News and World Report has recognized Sentara as having the Best Hospitals for 15+ years. Sentara offers professional development and a continued employment philosophy!