Fraud and Abuse Investigator – CPC

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

📋 Description

• Identify, investigate, analyze, and assess potential instances of fraud, waste, and abuse.

• Conduct interviews or communicate with patients, providers, witnesses, and other pertinent parties.

• Assess outcomes related to settlements, denials, or reviews.

• Analyze information gathered during investigations and present findings and recommendations in written summaries or presentations.

• Acquire knowledge and perform statistical sampling on complex medical claims.

• Assist in the preparation of settlements.

• Contribute to comprehensive investigations involving providers, pharmacies, employers, members, and brokers.

• Evaluate coding accuracy during routine desk audits and occasional on-site audits.

• Review reimbursement systems associated with health insurance claims processing.

• Ensure compliance with health plan policies and procedures.

⛳️ Requirements

• A minimum of 2 years of combined experience in Internal/External Audit, regulatory/compliance, or healthcare is preferred.

• A Bachelor's degree is preferred.

• Certification as a Professional Coder is preferred (or must be obtained within 12 months of the hire date).

• Ability to work from 8 AM to 5 PM EST, Monday through Friday.

• Eligibility for remote work in one of the specified states.

• Willingness to travel to Virginia Beach once a year.

🏝️ 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, Short-Term Disability, and Critical Illness plans.

• Life Insurance.

• 401k/403B with Employer Match.

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

• Student Debt Pay Down – $10,000.

• Pet Insurance.

• Legal Resources Plan.

• Annual discretionary bonus opportunity based on established system and employee eligibility criteria.

• Commitment to professional development and a philosophy of continued employment.