Remote Fraud & Abuse Investigator (CPC)

Sentara Health; Tennessee; À distance; USD 44 000 - 63 000; Plein temps

Avantages offerts par ce poste

Medical, Dental, Vision plans

Tuition Assistance

Paid Time Off

Parental Leave

Life Insurance

Résumé du poste

Sentara Health Plan is hiring an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) for a remote role. The position is full-time, with 40 hours per week and standard 8am–5pm EST, Monday through Friday. Remote work is available for many states, with annual Virginia Beach travel.

The role focuses on conducting in-depth fraud/abuse investigations, auditing coding quality, and reviewing reimbursement systems. A CPC certification is required, with CFE/AHFI preferred.

Qualifications

• Bachelor's Degree REQUIRED.
• Minimum of 2 years combined experience in Medical Coding OR Healthcare (Medical Chart Review/Insurance Billing) OR Internal/External Audit OR Regulatory/Compliance OR Claims Investigations OR Criminal Investigation/White Collar Crime REQUIRED.

Responsabilités

• Contribute to in-depth investigations for suspected fraud or abuse across provider, pharmacy, employer, member and broker interactions.
• Review the quality of pharmacy, physician, and hospital coding in routine audits and on-site audits.
• Review reimbursement systems and ensure adherence to policies for product offerings.
• Triage and prioritize leads and complaints, review referrals, assist in investigations, conduct research.
• Collect and evaluate suspicious patterns in claims data and provider enrollment data; refer to Investigator for further action.
• Ensure accurate reimbursement and compliant coding; maintain comprehensive case files; participate in special projects.

Connaissances

Professional Writing

Verbal Communication

Time Management

Problem Solving

Excel & Outlook

Formation

Bachelor's Degree

2+ years healthcare coding/audit/claims investigations

Outils

Microsoft Excel

Microsoft Word

Microsoft Access

Description du poste

Sentara Health Plan is hiring an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) for a remote role. The position is full-time, with 40 hours per week and standard 8am–5pm EST, Monday through Friday. Remote work is available for many states, with annual Virginia Beach travel.

The role focuses on conducting in-depth fraud/abuse investigations, auditing coding quality, and reviewing reimbursement systems. A CPC certification is required, with CFE/AHFI preferred.