Remote Fraud & Abuse Investigator | CPC-Certified

Sentara Health; South Carolina; 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 seeks an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) for remote work in eligible states. This full-time role features 8am–5pm EST, with annual travel to Virginia Beach and travel requirements.

Responsibilities include investigating fraud/abuse across providers and claims, reviewing coding audits, and ensuring compliant reimbursement. CPC required with potential CFE/AHFI preferred.

Qualifications

• Bachelor's Degree REQUIRED OR
• Minimum of 2 years combined experience required 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
• Certified Professional Coder (CPC) REQUIRED (or achieved within 12 months of hire date)
• Certified Fraud Examiner (CFE) OR Accredited Health Care Fraud Investigator (AHFI) preferred

Responsibilities

• Contribute to in-depth investigations for suspected fraud or abuse involving providers, pharmacy, employer, member, and broker interactions across products.
• Review the quality of coding in routine desk audits and occasional on-site audits.
• Review reimbursement systems in claims processing to ensure policy adherence.
• Triage and prioritize leads and member complaints; assist in investigation of potential fraud, waste and abuse.
• Conduct research in support of investigations and collect potential suspicious patterns in claims data and provider enrollment data.

Skills

Verbal communication

Professional writing

Time management

Complex problem solving

Microsoft Excel

Microsoft Word

Microsoft Access

Outlook

Education

Bachelor's Degree

Job description

Sentara Health Plan seeks an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) for remote work in eligible states. This full-time role features 8am–5pm EST, with annual travel to Virginia Beach and travel requirements.

Responsibilities include investigating fraud/abuse across providers and claims, reviewing coding audits, and ensuring compliant reimbursement. CPC required with potential CFE/AHFI preferred.