Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) - Remote!
Sentara Health
Summary
Sentara Health Plan is hiring an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) Remote. Full-time, permanent position (40 hours), 8am to 5pm EST, M-F. Remote for candidates living in VA, NC, AL, DE, FL, GA, ID, IN, KS, LA, ME, MD, MN, NE, NV, NH, ND, OH, OK, PA, SC, SD, TN, TX, UT, WA, WV, WI, WY, with travel to Virginia Beach 1x a year.
Job description
Overview
Sentara Health Plan is hiring an Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) Remote. Full-time, permanent position (40 hours), 8am to 5pm EST, M-F. Remote for candidates living in VA, NC, AL, DE, FL, GA, ID, IN, KS, LA, ME, MD, MN, NE, NV, NH, ND, OH, OK, PA, SC, SD, TN, TX, UT, WA, WV, WI, WY, with travel to Virginia Beach 1x a year.
Job Responsibilities
- Contribute to in-depth investigations for suspected fraud or abuse with respect to provider, pharmacy, employer, member, and broker interactions involving the full range of products.
- Contribute to the review of the quality of pharmacy, physician, ancillary and hospital based coding in routine desk audits as well as occasional on-site audits.
- Contribute to the review of reimbursement systems relating to health insurance claims processing and ensure adherence to policies and procedures for its various product offerings.
- Triage and prioritize leads/member complaints from internal sources.
- Review and assess incoming referrals; assist in the investigation of potential fraud, waste, and abuse.
- Conduct research in support of an investigation.
- Collect and evaluate potential suspicious patterns in claims data, provider enrollment data, and other sources and refer to Investigator for investigation or settlement.
- Assure accurate reimbursement is obtained and coding practices are compliant.
- Maintain comprehensive case files.
- Participate in special projects as required.
Education
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.
Certifications/Licenses
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.
Job Skills
Professional Writing, Verbal Communication, Time Management, Complex Problem Solving/Critical Thinking, Microsoft Excel and Word, Microsoft Access and Outlook.
Requirements
- Bachelor's Degree required OR minimum of 2 years combined experience in Medical Coding, Healthcare (Medical Chart Review/Insurance Billing), Internal/External Audit, Regulatory/Compliance, Claims Investigations, or Criminal Investigation/White Collar Crime
- 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
- Professional writing skills
- Verbal communication skills
- Time management skills
- Complex problem solving/critical thinking
- Microsoft Excel and Word
- Microsoft Access and Outlook
Benefits
- Medical, Dental & Vision
- Adoption, Fertility & Surrogacy Reimbursement
- Paid Time Off & Sick Leave
- Paid Parental & Family Caregiver Leave
- Emergency Backup Care
- Long-Term & Short-Term Disability
- Critical Illness Plans
- Life Insurance
- 401(k)/403(b) Employer Match
- Tuition Assistance
- Student Debt Pay Down
- Pet Insurance
- Legal Resources Plan
- Annual Discretionary Bonus
Company overview
Sentara Health is a leading not-for-profit integrated healthcare delivery system serving Virginia, northeastern North Carolina, and Florida. Founded in 1888 and headquartered in Hampton Roads, Virginia, Sentara operates 12 acute care hospitals across its service area, with 10 hospitals holding prestigious Magnet® recognition for nursing excellence. The organization employs approximately 34,000 healthcare professionals and serves over 1 million health plan members through its Sentara Health Plans division. As one of the top 20 largest not-for-profit integrated health systems in the United States, Sentara is nationally recognized for clinical quality, safety, and innovation. The system has received numerous accolades including Health Quality Innovator of the Year (2024), Forbes' "America's Best-In-State Employer" (2024), and inclusion in IBM Watson Health's "Top 15 Health Systems." Sentara's comprehensive services span hospital care, outpatient facilities, home health, hospice services, and specialized programs like the Nightingale air ambulance service, which has completed over 20,000 missions since 1982.