Remote Fraud & Abuse Investigator | CPC

Sentara Health; Maryland; Remote; USD 44,000 - 63,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

Paid Time Off and Sick Leave

Paid Parental & Family Caregiver Leave

Tuition Assistance – $5,250/year

Student Debt Pay Down – $10,000

Job summary

Sentara Health Plan is hiring an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) for a remote role. The position is full-time (40 hours) with shifts 8am-5pm EST, M-F, and remote for multiple states including MD, VA, NC and others, with annual travel to Virginia Beach.

The role emphasizes investigations into fraud/abuse, audit activities, and ensuring compliant coding and reimbursement.

Qualifications

• Bachelor's degree is REQUIRED.
• Minimum 2 years combined experience in Medical Coding/Healthcare/Audit/Compliance/Investigations is REQUIRED.
• Certified Professional Coder (CPC) is REQUIRED or achievable within 12 months of hire date.
• Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) preferred.

Responsibilities

• Contribute to in-depth investigations for suspected fraud or abuse across provider, pharmacy, employer, member, and broker interactions.
• Review coding quality in routine audits for pharmacy, physician, ancillary and hospital-based coding.
• Review reimbursement systems and ensure adherence to policies for product offerings.
• Triage and prioritize leads/member complaints; assist in investigations.
• Conduct research to support an investigation.
• Collect and evaluate suspicious patterns in claims data and provider enrollment data and refer to Investigator for investigation.
• Ensure accurate reimbursement and compliant coding; maintain comprehensive case files.
• Participate in special projects as required.

Skills

Professional Writing

Verbal Communication

Time Management

Complex Problem Solving/Critical Think

Microsoft Excel

Microsoft Word

Microsoft Access

Microsoft Outlook

Education

Bachelor's Degree

2+ years combined experience in Medical Coding/Healthcare/Audit/Compliance/Investigations

Tools

CPC Certification

Job description

Sentara Health Plan is hiring an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) for a remote role. The position is full-time (40 hours) with shifts 8am-5pm EST, M-F, and remote for multiple states including MD, VA, NC and others, with annual travel to Virginia Beach.

The role emphasizes investigations into fraud/abuse, audit activities, and ensuring compliant coding and reimbursement.