Associate Fraud and Abuse Investigator, Certified Professional Coder (CPC)
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Job Description
Remote Associate Fraud and Abuse Investigator/CPC auditing healthcare claims and coding for Sentara Health Plan. Investigating suspected fraud, waste, and abuse across health plan products.
Responsibilities:
- Contribute to in-depth investigations of suspected fraud or abuse involving providers, pharmacies, employers, members, and brokers across the full range of products
- Contribute to routine desk audits and occasional on-site audits reviewing pharmacy, physician, ancillary, and hospital-based coding quality
- Review reimbursement systems for health insurance claims processing and ensure adherence to policies and procedures
- Triage and prioritize leads and member complaints from internal sources
- Review and assess referrals and assist in investigating potential fraud, waste, and abuse
- Conduct research supporting investigations
- Collect and evaluate suspicious patterns in claims data, provider enrollment data, and other sources, referring cases to investigators for investigation or settlement
- Ensure accurate reimbursement and compliant coding practices
- Maintain comprehensive case files
- Participate in special projects as required
- Travel to Virginia Beach once a year
Requirements:
- Bachelor's Degree REQUIRED OR minimum of 2 years combined experience required in Medical Coding, Healthcare (Medical Chart Review/Insurance Billing), Internal/External Audit, Regulatory/Compliance, Claims Investigations, or Criminal Investigation/White Collar Crime
- Certified Professional Coder (CPC) REQUIRED or achieved within 12 months of hire date
- Certified Fraud Examiner (CFE) OR Accredited Health Care Fraud Investigator (AHFI) preferred
- Professional Writing
- Verbal Communication
- Time Management
- Complex Problem Solving/Critical Thinking
- Microsoft Excel and Word
- Microsoft Access and Outlook
- Must live in one of the listed 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
- Available to work 8am to 5pm EST, Monday through Friday
- Full-time availability, 40 hours per week
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
- Annual discretionary bonus opportunity if established system and employee eligibility criteria is met
- Paid military leave
- Voluntary benefits
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