Fraud and Abuse Investigator / CPC - Remote
About The Position
Sentara Health Plan is currently hiring a Fraud and Abuse Investigator/Certified Professional Coder (CPC) Remote! This is a full-time, permanent position (40 hours) with work hours from 8am to 5pm EST, Monday through Friday. The position is remote for candidates residing in specific states: Virginia, North Carolina, Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington (state), West Virginia, Wisconsin, Wyoming. Occasional travel to Virginia Beach is required once a year. The role is responsible for contributing to in-depth investigations of suspected fraud or abuse involving providers, pharmacies, employers, members, and brokers across all Sentara Health Plans lines of business. It also involves reviewing the quality of pharmacy, physician, ancillary, and hospital-based coding through routine desk audits and occasional on-site audits. The position contributes to the review of reimbursement systems related to health insurance claims processing and ensures adherence to health plan policies and procedures for its various product offerings.
Requirements
- 2 years combined experience required in Internal/External Audit OR regulatory/Compliance OR Healthcare preferred
- Certified Professional Coder preferred (or achieved within 12 months of hire date)
Nice To Haves
- Bachelor's degree preferred
Responsibilities
- Identify, investigate, analyze, and evaluate instances of potential fraud, waste, and abuse.
- Conduct interviews or correspond with patients, providers, witnesses, or other relevant parties to determine settlement, denial, or review.
- Analyze information gathered by investigation and report findings and recommendations as a written summary and/or presentation.
- Learn and conduct statistical sampling of complex medical claims.
- Assists in drafting settlements.
Benefits
- Medical, Dental, Vision plans
- Adoption, Fertility and Surrogacy Reimbursement up to $10,000
- Paid Time Off and Sick Leave
- Paid Parental & Family Caregiver Leave
- Emergency Backup Care
- Long-Term, Short-Term Disability, and Critical Illness plans
- Life Insurance
- 401k/403B with Employer Match
- Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education
- Student Debt Pay Down – $10,000
- Pet Insurance
- Legal Resources Plan
- Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
