Associate Fraud and Abuse Investigator, Certified Professional Coder (CPC)

This is a fully remote position, open to applicants in Alabama, +25 more states.

📋 Description

• Assist in comprehensive investigations of suspected fraud or abuse involving providers, pharmacies, employers, members, and brokers across a diverse range of products.

• Engage in regular desk audits and occasional on-site audits to evaluate coding quality for pharmacies, physicians, ancillary services, and hospitals.

• Analyze reimbursement systems for health insurance claims processing, ensuring compliance with policies and procedures.

• Prioritize and manage leads and member complaints received from internal sources.

• Review and evaluate referrals, aiding in the investigation of potential fraud, waste, and abuse.

• Conduct research that supports ongoing investigations.

• Gather and analyze suspicious patterns in claims data, provider enrollment data, and other relevant sources, referring cases to investigators for further action or resolution.

• Ensure precise reimbursement and adherence to compliant coding practices.

• Maintain detailed and organized case files.

• Participate in special projects as needed.

• Travel to Virginia Beach once a year.

⛳️ Requirements

• A Bachelor's Degree is REQUIRED OR a minimum of 2 years of combined experience in Medical Coding, Healthcare (Medical Chart Review/Insurance Billing), Internal/External Auditing, Regulatory/Compliance, Claims Investigations, or Criminal Investigation/White Collar Crime is required.

• Certified Professional Coder (CPC) is REQUIRED or must be obtained within 12 months of the hire date.

• Certification as a Fraud Examiner (CFE) or as an Accredited Health Care Fraud Investigator (AHFI) is preferred.

• Proficient in Professional Writing.

• Strong Verbal Communication skills.

• Effective Time Management abilities.

• Skills in Complex Problem Solving and Critical Thinking.

• Proficiency in Microsoft Excel and Word.

• Experience with Microsoft Access and Outlook.

• Must reside in one of the specified states: 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, or WY.

• Availability to work from 8 am to 5 pm EST, Monday through Friday.

• Full-time commitment of 40 hours per week.

🏝️ 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 services.

• Long-Term and Short-Term Disability, along with Critical Illness plans.

• Life Insurance coverage.

• 401k/403B with Employer Match.

• Tuition Assistance of $5,250 per year and discounted educational opportunities through Guild Education.

• Student Debt Pay Down benefit of $10,000.

• Pet Insurance options.

• Legal Resources Plan.

• Opportunity for an annual discretionary bonus if established criteria are met.

• Paid military leave.

• Voluntary benefits available.