Remote Fraud & Abuse Investigator (CPC)

Sentara Health; Richmond (VA); Remote; USD 73,000 - 110,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

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

Paid Time Off

Tuition Assistance

Employee discounts

Job summary

Sentara Health Plans is hiring a Fraud and Abuse Investigator/Certified Professional Coder (CPC) for a remote, full-time role. The position supports in-depth investigations across providers, pharmacies, employers, members and brokers, and reviews coding quality during routine audits.

A Bachelor's degree is preferred, CPC certification is preferred (or within 12 months of hire), and about 2 years of related experience in audits, compliance or healthcare analytics is expected.

Qualifications

• Bachelor's degree preferred.
• Certified Professional Coder (CPC) preferred (or achieved within 12 months of hire).
• 2 years combined experience in Internal/External Audit OR regulatory/Compliance OR Healthcare preferred.
• Experience reviewing claims, analyzing data, identifying billing irregularities and supporting pre-pay review activities.

Responsibilities

• Identify, investigate, analyze, and evaluate instances of potential fraud, waste and abuse.
• Conduct interviews with patients, providers, witnesses, or other relevant parties to determine settlements or reviews.
• Analyze information gathered by investigation and report findings with recommendations.
• Learn and conduct statistical sampling of complex medical claims.
• Assist in drafting settlements.

Skills

Fraud, waste & abuse concepts

Data analysis

Investigative interviewing

Education

Bachelor's degree

Job description

Sentara Health Plans is hiring a Fraud and Abuse Investigator/Certified Professional Coder (CPC) for a remote, full-time role. The position supports in-depth investigations across providers, pharmacies, employers, members and brokers, and reviews coding quality during routine audits.

A Bachelor's degree is preferred, CPC certification is preferred (or within 12 months of hire), and about 2 years of related experience in audits, compliance or healthcare analytics is expected.