Fraud and Abuse Investigator, CPC

Sentara Health

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

Posted 11/6/2026full-timeRemote • United StatesJuniorMid-Level💰 $72,613 - $109,990 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in fraud, waste, and abuse analysis within healthcare, utilizing data analysis and statistical sampling to evaluate claims and provider billing patterns. Proficient in conducting audits and ensuring compliance with health plan policies and procedures.

Highest-signal resume keywords

Fraud, Waste, And Abuse AnalysisHealthcare Claims ReviewData AnalysisCertified Professional CoderInternal/External Audit Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Statistical SamplingClaims AnalysisInvestigation ReportingSettlement DraftingDesk AuditsOn-Site AuditsReimbursement Systems ReviewBilling Irregularities IdentificationPre-Pay Review ActivitiesHealthcare Compliance

Soft Skills

CommunicationInterpersonal SkillsAnalytical ThinkingAttention To Detail

Certifications & Qualifications

Certified Professional Coder

Industry Keywords

HealthcareHealth InsuranceProvider Billing PatternsMedicareMedicaidCommercial Health PlansEmployee Assistance ProgramsRegulatory Compliance

About the role

Key responsibilities & impact

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

What you’ll need

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

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