Remote Fraud & Abuse Investigator (CPC)

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

Benefits offered by this job

Bonus opportunities

Comprehensive benefits package

Paid time off (vacation, sick time, 18

Job summary

Sentara Health Plans is seeking an Associate Fraud and Abuse Investigator / Certified Professional Coder (CPC) for a remote role. The position supports remote work with annual travel to Virginia Beach and requires 40 hours per week as a full-time, permanent role.

The role involves in-depth investigations of suspected fraud and abuse, coding quality reviews, and review of reimbursement systems. A Bachelor's degree and 2+ years in Medical Coding or related fields are required, with CFE/AHFI

Qualifications

• Bachelor's Degree required.
• Minimum of 2 years combined experience in Medical Coding or Healthcare related field.
• CFE or AHFI certification preferred.

Responsibilities

• Contribute to in-depth investigations for suspected fraud or abuse across providers, pharmacy, employer, member, and broker interactions.
• Review the quality of coding in pharmacy, physician, and hospital-based settings through audits.
• Review reimbursement systems and ensure adherence to policies for product offerings.
• Triage and prioritize leads and member complaints from internal sources.
• Assist in investigation activities, conduct research, and collect patterns in claims or enrollment data for investigation.

Skills

Fraud investigations

Medical coding

Regulatory/compliance

Communication skills

Microsoft Excel

Time management

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 remote work with annual travel to Virginia Beach and requires 40 hours per week as a full-time, permanent role.

The role involves in-depth investigations of suspected fraud and abuse, coding quality reviews, and review of reimbursement systems. A Bachelor's degree and 2+ years in Medical Coding or related fields are required, with CFE/AHFI