Fraud and Abuse Investigator, CPC

This is a fully remote position, open to applicants in Alabama, +26 more locations.

📋 Description

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

• Conduct interviews or communicate with patients, providers, witnesses, or other relevant parties to determine settlement, denial, or review outcomes.

• Analyze investigation data and present findings and recommendations through written summaries and/or presentations.

• Acquire knowledge and perform statistical sampling of intricate medical claims.

• Assist in drafting settlement agreements.

• Contribute to comprehensive investigations involving interactions among providers, pharmacies, employers, members, and brokers across Sentara Health Plans' various lines of business.

• Participate in routine desk audits and occasional on-site audits of pharmacy, physician, ancillary, and hospital-based coding.

• Review reimbursement systems associated with health insurance claims processing.

• Ensure compliance with health plan policies and procedures across different product offerings.

• Support Sentara Health Plans, which offers commercial, Individual & Family, Medicare, Medicaid, and Employee Assistance health plans.

⛳️ Requirements

• A minimum of 2 years of combined experience in Internal/External Audit, regulatory/Compliance, or Healthcare is required.

• Experience in reviewing claims, analyzing data, identifying potential billing discrepancies, and assisting with pre-pay review activities.

• A Bachelor's degree is preferred.

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

• Familiarity with healthcare claims, provider billing patterns, and concepts related to fraud, waste, and abuse (FWA), along with the use of data analysis to pinpoint claims or providers needing further review, is preferred.

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

• Must reside in one of the eligible 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.

• Willingness to travel to Virginia Beach once a year.

• Certification as a Professional Coder must be obtained within 12 months of hire if not already held.

🏝️ 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 of $5,250 per year and discounted educational opportunities through Guild Education.

• Student Debt Pay Down of $10,000.

• Pet Insurance.

• Legal Resources Plan.

• Annual discretionary bonus contingent upon established system and employee eligibility criteria.

• Remote work arrangement.

• Paid military leave.

• Voluntary benefits.