Fraud and Abuse Investigator / CPC - Remote
$53,248–$88,754 year
RemoteTexas, United States or Washington, United States
Job Summary
Conduct in-depth investigations for suspected fraud or abuse involving provider, pharmacy, employer, member, and broker interactions. Review the quality of pharmacy, physician, ancillary, and hospital-based coding during routine and occasional on-site desk audits. Analyze information to determine settlement, denial, or review outcomes while learning statistical sampling of complex medical claims. Draft written summaries and recommendations based on findings, and assist in drafting settlements. Ensure adherence to health plan policies for reimbursement systems and claims processing. This role supports Sentara Health Plans' mission to improve health for close to one million members through integrity and program integrity initiatives.
Required Qualifications
- Bachelor's degree
- 2 years combined experience required in Internal/External Audit OR regulatory/Compliance OR Healthcare
- Certified Professional Coder (CPC)
- Certifications/Licenses: Certified Professional Coder preferred (or achieved within 12 months of hire date)
- With travel to Virginia Beach 1x a year
Desired Qualifications
- Bachelor's degree preferred
- Certified Professional Coder preferred (or achieved within 12 months of hire date)
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