Remote Fraud & Abuse Investigator - CPC Certified

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

Benefits offered by this job

Medical, Dental, Vision plans

401k/403B with employer match

Paid Time Off and Holidays

Education assistance

Job summary

Sentara Health Plan is hiring an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) for a remote role. This full-time position includes 8am–5pm EST shifts, with travel to Virginia Beach once yearly. Remote work is possible for residents in multiple states, including Florida.

You will conduct in-depth investigations, review coding quality, and ensure compliant reimbursement. A CPC certification is required or obtained within 12 months of hire, with a Bachelor's degree and

Qualifications

• Bachelor's degree required.
• 2+ years combined experience in Medical Coding, Healthcare, Audit, Compliance, or Investigations required.
• CPC certification required or achieved within 12 months of hire date.
• CFE or AHFI preferred.

Responsibilities

• Contribute to in-depth investigations for suspected fraud or abuse across provider, pharmacy, employer, member, and broker interactions.
• Review coding quality across pharmacy, physician, and hospital-based coding.
• Review reimbursement systems to ensure adherence to policies for products offered.
• Triage leads and member complaints; assist in investigations of potential fraud, waste, and abuse.
• Conduct research to support investigations and evaluate suspicious patterns in claims and enrollment data.
• Maintain comprehensive case files and participate in special projects as required.

Skills

Verbal Communication

Time Management

Complex Problem Solving

Professional Writing

Microsoft Excel

Microsoft Word

Outlook

Microsoft Access

Education

Bachelor's Degree

2+ years experience in Medical Coding/Healthcare/ Audit/ Compliance/ Investigations

Job description

Sentara Health Plan is hiring an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) for a remote role. This full-time position includes 8am–5pm EST shifts, with travel to Virginia Beach once yearly. Remote work is possible for residents in multiple states, including Florida.

You will conduct in-depth investigations, review coding quality, and ensure compliant reimbursement. A CPC certification is required or obtained within 12 months of hire, with a Bachelor's degree and