Remote Fraud & Abuse Investigator (CPC Eligible)

Sentara Health; Virginia; Hybrid; USD 73,000 - 110,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

401k/403B with employer match

Paid Time Off & Holidays

Educational assistance

Job summary

Sentara Health Plans is seeking a Fraud and Abuse Investigator with CPC certification for a remote, full-time role in the Virginia area. Work hours are 8am–5pm EST, Monday–Friday, with travel to Virginia Beach once yearly.

The ideal candidate will investigate potential fraud, perform data-driven claim analyses, and contribute to on-site audits as needed, ensuring adherence to health plan policies and procedures across Sentara Health Plans’ product lines.

Qualifications

• 2 years combined experience in Internal/External Audit or regulatory/compliance or healthcare preferred.
• Familiarity with healthcare claims, provider billing patterns, fraud, waste and abuse (FWA) concepts.
• Experience reviewing claims and using data analysis to identify review-needed items.

Responsibilities

• Identify, investigate, analyze, and evaluate instances of potential fraud, waste, and abuse.
• Conduct interviews or correspondence with patients, providers, witnesses, or other relevant parties to determine settlement, denial, or review.
• Analyze information gathered by investigation and report findings and recommendations in writing or presentation.
• Learn and conduct statistical sampling of complex medical claims.
• Assist in drafting settlements.

Skills

Fraud and Abuse Investigations

Certified Professional coder CPC

Data analysis

Claims review

Regulatory/compliance

Education

Bachelor's degree preferred

Job description

Sentara Health Plans is seeking a Fraud and Abuse Investigator with CPC certification for a remote, full-time role in the Virginia area. Work hours are 8am–5pm EST, Monday–Friday, with travel to Virginia Beach once yearly.

The ideal candidate will investigate potential fraud, perform data-driven claim analyses, and contribute to on-site audits as needed, ensuring adherence to health plan policies and procedures across Sentara Health Plans’ product lines.