Remote Fraud & Abuse Investigator | CPC-Certified

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

Benefits offered by this job

Medical, Dental, Vision plans

Tuition Assistance

Paid Time Off

Life Insurance

401k/403B with Employer Match

Job summary

Sentara Health Plan is currently hiring an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) remote. This full-time role focuses on in-depth investigations of potential fraud and ensuring compliant coding and reimbursement practices across multiple product lines.

Qualifications include a Bachelor's degree, CPC certification (or within 12 months), and 2+ years in medical coding or healthcare. Remote work is available to many states with annual travel to Virginia Beach.

Qualifications

• Bachelor's Degree REQUIRED.
• Minimum 2 years combined experience in Medical Coding or healthcare related field REQUIRED.
• Certified Professional Coder (CPC) REQUIRED or achieved within 12 months of hire.
• CFE or AHFI preferred.

Responsibilities

• Contribute to in-depth investigations for suspected fraud or abuse across provider, pharmacy, employer, member, and broker interactions.
• Review quality of pharmacy, physician, and hospital coding in desk audits and occasional on-site audits.
• Review reimbursement systems and ensure adherence to policies for product offerings.
• Triage and prioritize leads and member complaints.
• Assist in investigation of potential fraud, waste and abuse.
• Collect and evaluate suspicious patterns in claims data and provider enrollment data.
• Ensure accurate reimbursement and compliant coding; maintain case files.

Skills

Professional Writing

Verbal Communication

Time Management

Complex Problem Solving

Microsoft Excel

Microsoft Word

Microsoft Access

Outlook

Education

Bachelor's Degree

Job description

Sentara Health Plan is currently hiring an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) remote. This full-time role focuses on in-depth investigations of potential fraud and ensuring compliant coding and reimbursement practices across multiple product lines.

Qualifications include a Bachelor's degree, CPC certification (or within 12 months), and 2+ years in medical coding or healthcare. Remote work is available to many states with annual travel to Virginia Beach.