Sentara Health · 1 day ago
Associate Fraud and Abuse Investigator
United States
Full-time
Remote
Entry Level
$22.36/hr - $37.26/hr
2+ years expSentara Health is a healthcare organization providing health plan coverage to nearly one million members in Virginia. The Associate Fraud and Abuse Investigator will contribute to investigations of suspected fraud or abuse and assist in reviewing coding quality and reimbursement systems.
Hospital & Health Care
Responsibilities
Responsible for contributing to in-depth investigations for suspected fraud or abuse with respect to provider, pharmacy, employer, member, and broker interactions involving the full range of products
Responsible for contributing to the review of the quality of pharmacy, physician, ancillary and hospital based coding in routine desk audits as well as occasional on-site audits
Contribute to the review of reimbursement systems relating to health insurance claims processing and ensures adherence to policies and procedures for its various product offerings
Specific progression of responsibility is a follows dependent upon education, certifications, and experience:
Triage and prioritize leads/member complaints from internal sources
Review and assess incoming referrals; Assist in the investigation of potential fraud, waste, and abuse
Conduct research in support of an investigation
Collect and evaluate potential suspicious patterns in claims data, provider enrollment data, and other sources and refers to Investigator for investigation or settlement
Assures accurate reimbursement is obtained and coding practices are compliant
Maintain comprehensive case files
Participates in special projects as required
Qualification
Required
Bachelor's Degree REQUIRED
Minimum of 2 years combined experience required in Medical Coding OR Healthcare (Medical Chart Review/Insurance Billing) OR Internal/External Audit OR Regulatory/Compliance OR Claims Investigations OR Criminal Investigation/White Collar Crime REQUIRED
Certified Professional Coder (CPC) REQUIRED (or achieved within 12 months of hire date)
Professional Writing
Verbal Communication
Time Management
Complex Problem Solving/Critical Thinking
Microsoft Excel and Word
Microsoft Access and Outlook
Preferred
Certified Fraud Examiner (CFE)
Accredited Health Care Fraud Investigator (AHFI)
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
Reimbursement for certifications and free access to complete CEUs and professional development
Pet Insurance
Legal Resources Plan
Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.
Company
Sentara Health
Sentara Health, an integrated, not-for-profit health care delivery system, celebrates more than 135 years in pursuit of its mission - "we improve health every day." Sentara is one of the largest health systems in the U.S.
10001+ employees
Funding
Current Stage
Late StageLeadership Team
Dennis Matheis
President & CEO
Howard Kern
CEO Emeritus Sentara Health
Recent News
2025-09-17
The Virginian-Pilot
2025-07-24
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