Remote Fraud & Abuse Investigator (CPC)

Sentara Health Plans; Norfolk (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 a remote role. The position supports in-depth investigations into potential fraud or abuse across provider, pharmacy, employer, member, and broker interactions, with coding reviews and audits as part of the workflow.

The role requires a Bachelor's Degree or equivalent experience and CPC certification (or to obtain within 12 months).

Qualifications

• Bachelor's degree required or equivalent experience in medical coding or healthcare audit/compliance.
• Experience in coding reviews, claims processing, or investigations preferred.
• Certified Professional Coder (CPC) required or to be achieved within 12 months.

Responsibilities

• Contribute to in-depth investigations for suspected fraud or abuse across providers, pharmacy, employer, member, and broker interactions.
• Review and assess coding accuracy in audits and desk/on-site reviews.
• Support review of reimbursement systems and claims processing policy adherence.
• Document case files and participate in special projects as required.

Skills

Professional Writing

Verbal Communication

Time Management

Complex Problem Solving/Critical Think

Microsoft Excel

Microsoft Word

Microsoft Access

Outlook

Education

Bachelor's Degree

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

Tools

Microsoft Excel

Microsoft Word

Microsoft Access

Outlook

Job description

Sentara Health Plans is seeking an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) for a remote role. The position supports in-depth investigations into potential fraud or abuse across provider, pharmacy, employer, member, and broker interactions, with coding reviews and audits as part of the workflow.

The role requires a Bachelor's Degree or equivalent experience and CPC certification (or to obtain within 12 months).