Remote Fraud & Abuse Investigator (CPC)

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

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 of suspected fraud, waste, and abuse across providers, pharmacies, and members, with occasional travel to Virginia Beach.

The role requires a Bachelor's degree and at least 2 years of combined experience in medical coding or healthcare, plus a CFE or AHFI certification.

Qualifications

• Bachelor's Degree required.
• Minimum of 2 years combined experience in Medical Coding, Healthcare, or related compliance/audit fields.
• Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI).
• Proficient in professional writing and MS Office tools.

Responsibilities

• Contribute to in-depth investigations for suspected fraud or abuse across providers, pharmacy, employer, member, and broker interactions.
• Review coding quality in routine desk audits and occasional on-site audits.
• Review reimbursement systems to ensure adherence to policies across product offerings.
• Triage and prioritize leads and member complaints from internal sources.
• Investigate potential fraud, collect and analyze data, and refer findings for investigation or settlement.
• Ensure accurate reimbursement and compliant coding.

Skills

Professional Writing

Verbal Communication

Time Management

Complex Problem Solving

Critical Thinking

Education

Bachelor's Degree

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 of suspected fraud, waste, and abuse across providers, pharmacies, and members, with occasional travel to Virginia Beach.

The role requires a Bachelor's degree and at least 2 years of combined experience in medical coding or healthcare, plus a CFE or AHFI certification.