Remote Fraud & Abuse Investigator (CPC)

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

Benefits offered by this job

Adoption reimbursement up to $10,000

Disability insurance

Life Insurance

Legal Resources Plan

Annual discretionary bonus

Job summary

Sentara Health Plan is seeking an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) for a remote, full-time role. Travel to Virginia Beach 1x per year, with state-remote eligibility.

You will contribute to in-depth fraud investigations and coding audits across multiple lines of health products. The role requires a Bachelor's degree with 2+ years in Medical Coding or related fields, plus professional fraud credentials (CFE or AHFI).

Qualifications

• Bachelor's degree required.
• Minimum of 2 years combined experience in Medical Coding, Healthcare, Internal/External Audit, Regulatory/Compliance, Claims Investigations or Criminal Investigation/White Collar Crime.
• Professional credentials: CFE or AHFI.

Responsibilities

• Assist in deep investigations for suspected fraud or abuse across provider, pharmacy, employer, member, and broker interactions.
• Review coding quality for pharmacy, physician, and hospital-based coding in desk audits and occasional on-site audits.
• Review reimbursement systems for health insurance claims processing and ensure adherence to policies.
• Triage and prioritize leads and member complaints; investigate potential fraud, waste, and abuse; collect and evaluate data for investigations.
• Ensure accurate reimbursement and compliant coding; participate in special projects as required.

Skills

Professional writing

Verbal communication

Time management

Critical thinking

Microsoft Excel

Microsoft Word

Microsoft Access

Outlook

Education

Bachelor's Degree

Certified Fraud Examiner (CFE)

Accredited Health Care Fraud Investigator (AHFI)

Tools

Excel

Word

Access

Outlook

Job description

Sentara Health Plan is seeking an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) for a remote, full-time role. Travel to Virginia Beach 1x per year, with state-remote eligibility.

You will contribute to in-depth fraud investigations and coding audits across multiple lines of health products. The role requires a Bachelor's degree with 2+ years in Medical Coding or related fields, plus professional fraud credentials (CFE or AHFI).