Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) - Remote!
About The Position
Sentara Health Plan is hiring a full-time, permanent Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC). The position is remote for candidates who reside in the listed eligible states, with travel to Virginia Beach once a year. Work hours are 8 a.m. to 5 p.m. Eastern Time, Monday through Friday, for 40 hours per week. The role contributes to in-depth investigations of suspected fraud or abuse involving providers, pharmacies, employers, members, and brokers across the full range of products. It also contributes to reviews of pharmacy, physician, ancillary, and hospital coding through routine desk audits and occasional on-site audits, and reviews reimbursement systems for adherence to policies and procedures. Responsibilities progress based on education, certifications, and experience. The associate triages and prioritizes leads and member complaints; reviews referrals and assists with investigations of potential fraud, waste, and abuse; researches cases; identifies suspicious patterns in claims, provider enrollment, and other data and refers them to an investigator for investigation or settlement; supports accurate reimbursement and compliant coding; maintains case files; and participates in special projects. Sentara Health Plan provides coverage to close to one million members in Virginia, with commercial, individual and family, employee assistance, Medicare, and Medicaid offerings. The organization describes a family-friendly culture that encourages community involvement and provides opportunities for development and growth.
Requirements
- Bachelor's degree, or at least two years of combined experience in medical coding, healthcare (medical chart review or insurance billing), internal or external audit, regulatory or compliance, claims investigations, or criminal investigation/white-collar crime.
- Certified Professional Coder (CPC), required or to be achieved within 12 months of hire.
- Professional writing skills.
- Verbal communication skills.
- Time-management skills.
- Complex problem-solving and critical-thinking skills.
- Microsoft Excel and Word skills.
- Microsoft Access and Outlook skills.
Nice To Haves
- Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI).
Responsibilities
- Triage and prioritize leads and member complaints from internal sources.
- Review and assess incoming referrals and assist in investigating potential fraud, waste, and abuse.
- Conduct research in support of investigations.
- Collect and evaluate potentially suspicious patterns in claims data, provider enrollment data, and other sources, and refer findings to an investigator for investigation or settlement.
- Help ensure accurate reimbursement and compliant coding practices.
- Contribute to in-depth investigations of suspected fraud or abuse involving providers, pharmacies, employers, members, and brokers across the full range of products.
- Contribute to reviews of pharmacy, physician, ancillary, and hospital-based coding in routine desk audits and occasional on-site audits.
- Contribute to reviews of reimbursement systems and ensure adherence to policies and procedures for various product offerings.
- Maintain comprehensive case files.
- Participate in special projects as required.
Benefits
- Medical, dental, and vision plans.
- Adoption, fertility, and surrogacy reimbursement up to $10,000.
- Paid time off and sick leave.
- Paid parental and family caregiver leave.
- Emergency backup care.
- Long-term and short-term disability and critical illness plans.
- Life insurance.
- 401(k)/403(b) with employer match.
- Tuition assistance of $5,250 per year and discounted educational opportunities through Guild Education.
- Student debt pay down up to $10,000.
- Pet insurance.
- Legal resources plan.
- Opportunity to earn an annual discretionary bonus, subject to system and employee eligibility criteria.
- Paid holidays.
- Educational assistance or student loan repayment.
- Voluntary benefits.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
