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Associate Fraud and Abuse Investigator, Certified Professional Coder (CPC)
Sentara Health. Contribute to in-depth investigations of suspected fraud or abuse involving providers, pharmacies, employers, members, and brokers across the full range of products .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Medical Coding, Healthcare Compliance, and Fraud Investigation, with a strong focus on accurate reimbursement and coding practices. Proficient in analyzing claims data and conducting thorough investigations to identify fraud, waste, and abuse.
Highest-signal resume keywords
Bachelor's DegreeCertified Professional Coder (CPC)Medical CodingClaims InvestigationsComplex Problem Solving
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical CodingClaims InvestigationsHealthcare ComplianceFraud InvestigationReimbursement Systems ReviewCoding Quality AuditsData AnalysisCase File ManagementDesk AuditsOn-Site Audits
Soft Skills
Professional WritingVerbal CommunicationTime ManagementCritical ThinkingProblem Solving
Tools & Technologies
Microsoft ExcelMicrosoft WordMicrosoft AccessMicrosoft Outlook
Certifications & Qualifications
Certified Professional Coder (CPC)Certified Fraud Examiner (CFE)Accredited Health Care Fraud Investigator (AHFI)
Industry Keywords
HealthcareFraudAbuseClaims ProcessingRegulatory ComplianceInternal AuditExternal AuditInsurance BillingMedical Chart ReviewProvider Enrollment
About the role
Key responsibilities & impact- 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
What you’ll need- 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
Comp & perks- 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