Fraud and Abuse Investigator / CPC - Remote

Norfolk, VA • First shift (Days)

About the role

Sentara Health Plan is hiring a remote Fraud and Abuse Investigator/Certified Professional Coder (CPC). This is a full-time, permanent position (40 hours per week) with work hours from 8:00 AM to 5:00 PM EST, Monday through Friday. The role is remote for candidates residing in the following states: Virginia, North Carolina, Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, West Virginia, Wisconsin, or Wyoming. Annual travel to Virginia Beach is required once per year.

Sentara Health Plans provides health plan coverage to nearly one million members in Virginia, offering a full suite of commercial products, including employer-sponsored and individual/family plans, as well as Medicare and Medicaid plans. The organization features a robust provider network and supports members with chronic illnesses, wellness programs, and integrated clinical and behavioral health services.

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.
• Assist in drafting settlements.
• Contribute to in-depth investigations for suspected fraud or abuse involving provider, pharmacy, employer, member, and broker interactions across Sentara Health Plans' lines of business.
• Contribute to the review of the quality of pharmacy, physician, ancillary, and hospital-based coding in routine desk audits and occasional on-site audits.
• Contribute to the review of reimbursement systems relating to health insurance claims processing and ensure adherence to health plan policies and procedures.

Requirements

• Bachelor’s degree preferred.
• Certified Professional Coder (CPC) certification preferred (or achieved within 12 months of hire date).
• 2 years of combined experience in Internal/External Audit, regulatory/Compliance, or Healthcare preferred.

Pay

The base pay rate for this full-time position is $25.60/hour to $42.67/hour. Additional compensation may include shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities. Colleagues may earn an annual discretionary bonus if established system and employee eligibility criteria are met.

Benefits

• Medical, Dental, and 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