Remote CPC Fraud & Abuse Investigator

Sentara Health; Richmond (VA); Remote; USD 44,000 - 63,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

401(k)/403(b) with employer match

Paid Time Off

Job summary

Sentara Health Plans is seeking an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) for remote work with state eligibility. The role supports in-depth investigations into fraud and coding quality for health plans, with annual travel to Virginia Beach.

A CPC credential and data-review experience are required or pursued upon hire. Responsibilities include reviewing provider and claims data, auditing reimbursement processes, and maintaining detailed case files.

Qualifications

• Bachelor's degree required or equivalent combination of education and experience.
• CPC certification required or to be achieved within 12 months of hire.
• Experience with medical coding, healthcare audits, or claims investigations is preferred.
• Strong writing, communication, and analytical skills are essential.

Responsibilities

• Contribute to in-depth investigations for suspected fraud or abuse across provider, pharmacy, employer, member, and broker interactions.
• Review coding quality for pharmacy, physician, and hospital-based services during audits and on-site visits.
• Assist in audits of reimbursement systems and ensure compliance with policies for multiple product offerings.
• Triage leads, review referrals, and help investigate potential fraud, waste, and abuse.
• Maintain comprehensive case files and participate in special projects as needed.

Skills

Professional Writing

Verbal Communication

Time Management

Complex Problem Solving

Critical Thinking

Microsoft Excel

Microsoft Word

Microsoft Access

Outlook

Education

Bachelor's Degree

Tools

CPC Certification

CFE

AHFI

FBITP

Job description

Sentara Health Plans is seeking an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) for remote work with state eligibility. The role supports in-depth investigations into fraud and coding quality for health plans, with annual travel to Virginia Beach.

A CPC credential and data-review experience are required or pursued upon hire. Responsibilities include reviewing provider and claims data, auditing reimbursement processes, and maintaining detailed case files.