Remote Fraud & Abuse Investigator (CPC Certified)

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

Benefits offered by this job

Health insurance

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

Educational assistance

Job summary

Sentara Health Plans is hiring for an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) in a remote role. The position offers full-time status with 40 hours weekly, primarily 8am–5pm EST, Monday–Friday.

Remote work is available for multiple states, with annual travel to Virginia Beach. Responsibilities include conducting investigations, auditing coding practices, and reviewing claims data to ensure compliant reimbursements.

Qualifications

• Bachelor's Degree REQUIRED or
• Minimum of 2 years combined experience in Medical Coding or Healthcare fields OR Audit/Compliance/Investigations
• CPC CERTIFICATION REQUIRED (or obtained 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 the quality of coding in routine desk audits and occasional on-site audits
• Review reimbursement systems and ensure adherence to policies for various product offerings
• Triage leads and member complaints, review referrals, and assist in investigations
• Collect and evaluate potential suspicious patterns in claims data and provider enrollment data
• Ensure accurate reimbursement and compliant coding
• Maintain comprehensive case files
• Participate in special projects as required

Skills

Professional Writing

Verbal Communication

Time Management

Critical Thinking

Microsoft Excel

Microsoft Word

Microsoft Access

Outlook

Education

Bachelor's Degree

Experience in Medical Coding / Healthcare / Auditing

Tools

Excel

Word

Access

Outlook

Job description

Sentara Health Plans is hiring for an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) in a remote role. The position offers full-time status with 40 hours weekly, primarily 8am–5pm EST, Monday–Friday.

Remote work is available for multiple states, with annual travel to Virginia Beach. Responsibilities include conducting investigations, auditing coding practices, and reviewing claims data to ensure compliant reimbursements.