Fraud and Abuse Investigator, CPC

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🔥 3 minutes ago

🏈 Alabama, Florida, +25 more states – Remote

🏈 Alabama – Remote 🐊 Florida – Remote 🥔 Idaho – Remote 🌪️ Kansas – Remote ⚜️ Louisiana – Remote 🦞 Maine – Remote 🌾 Nebraska – Remote 🎰 Nevada – Remote 🗻 New Hampshire – Remote 🌲 North Carolina – Remote 🌾 North Dakota – Remote 🏈 Ohio – Remote 🌪️ Oklahoma – Remote 🦀 Maryland – Remote ❄️ Minnesota – Remote 🔔 Pennsylvania – Remote 🌴 South Carolina – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote ⚔️ Virginia – Remote ☕ Washington – Remote ⛰️ West Virginia – Remote 🧀 Wisconsin – Remote 🦬 Wyoming – Remote 🍑 Georgia – Remote

💵 $72.6k - $110k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🚫👨‍🎓 No degree required

👻 Ghost score 0%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Sentara Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1890

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

Sentara Health is a leading healthcare system that operates over 300 sites of care in Virginia and northeastern North Carolina, including 12 acute care hospitals. The company is dedicated to providing exceptional patient care, fostering professional development, and maintaining a diverse workforce. Sentara Health aims to improve health every day and has been recognized for its clinical and operational performance, being named one of the top 15 health systems by IBM Watson Health. The organization supports its employees in achieving their full potential and encourages growth and innovation in the healthcare sector.

📋 Description

• Identify, investigate, analyze, and evaluate instances of potential fraud, waste, and abuse • Conduct interviews or correspond with patients, providers, witnesses, or other relevant parties to determine settlement, denial, or review • Analyze investigation information and report findings and recommendations in written summaries and/or presentations • Learn and conduct statistical sampling of complex medical claims • Assist in drafting settlements • Contribute to in-depth investigations involving provider, pharmacy, employer, member, and broker interactions across Sentara Health Plans' lines of business • Contribute to routine desk audits and occasional on-site audits of pharmacy, physician, ancillary, and hospital-based coding • Review reimbursement systems related to health insurance claims processing • Ensure adherence to health plan policies and procedures for various product offerings • Support Sentara Health Plans, which provides commercial, Individual & Family, Medicare, Medicaid, and Employee Assistance health plans

🎯 Requirements

• 2 years combined experience required in Internal/External Audit OR regulatory/Compliance OR Healthcare • Experience reviewing claims, analyzing data, identifying potential billing irregularities, and supporting pre-pay review activities • Bachelor's degree preferred • Certified Professional Coder preferred (or achieved within 12 months of hire date) • Familiarity with healthcare claims, provider billing patterns, fraud, waste and abuse (FWA) concepts, and the use of data analysis to identify claims or providers requiring further review is preferred • Ability to work 8am to 5pm EST, Monday through Friday • Must live 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 • Travel to Virginia Beach once a year • Certified Professional Coder certification within 12 months of hire if not already held

🏖️ 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 if established system and employee eligibility criteria is met • Remote work arrangement • Paid military leave • Voluntary benefits

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