[Hiring] CPC Investigator @Horizon Blue Cross Blue Shield of New Jersey

Role Description

The Certified Professional Coder (CPC) is responsible for performing reviews, audits and coding oversight of medical records to ensure the appropriate CPT codes, diagnosis codes and modifiers according to Generally Accepted Medical Coding Guidelines, CPT-4; HCPCS; ICD-10 Guidelines; and, CMS Correct Coding. The incumbent will also support the investigators related to research and resolution of fraudulent activity.

• Accurately reviews, interprets, audits, codes and analyzes medical record documentation for claims that are suspended for Special Investigations pre-payment process.
• Follow established procedures, guidelines and research utilizing multiple systems and tools.
• Assure timely, accurate and efficient processing and resolution of pended claims and service requests.
• Analyze and review confidential and highly sensitive investigative material/documents concerning employees, subscribers, providers and groups.
• Obtain documentation, claims forms, checks, medical records, utilization records, specialized printouts and other data needed to determine if fraud or misrepresentation of fact is present in claims submissions.
• Primary contact for other Blues Plans on any claim inquiries related to fraud investigations.
• Collecting, collating, analyzing and interpreting data in a timely, accurate fashion, both internally and externally, to gather the requisite documentation to conduct an investigation.
• Personally handles subpoena requests, coordinates efforts with law enforcement state agencies and claims stakeholders.
• Investigates calls received to the Fraud Hotline with legitimate allegations of fraud.
• Knowledge of CPT coding, HCPCS coding, and ICD 10.

Qualifications

• High School Diploma/GED required.
• 2 years’ experience in Health Insurance/quality chart audits and/or Utilization Review.
• 2-3 years’ medical coding experience.
• ITS/BlueCard Knowledge preferred.
• AAPC - Certified Professional Coding (CPC) Designation Required.

Requirements

• Requires knowledge of health insurance operations (i.e. claims, enrollment, underwriting, etc.)
• Prefers knowledge of claims processing and customer service systems (NASCO adjustment and pend processing, UPS, UCSW, Research Station, Cognos, and ImagePlus).
• Prefers knowledge of ITS/Blue card process.
• Prefers knowledge in Microsoft products (Word, Excel, and Access).
• Requires Medical Coding experience.
• Requires proficiency in the CPT-4, HCPC, ICD-9/ICD-10 coding.
• Requires knowledge of medical terminology and anatomy & physiology related to medical procedures, abbreviations and terms.
• Requires knowledge of the health care delivery system.

Skills and Abilities

• Requires excellent verbal and written communication skills.
• Requires the ability to effectively handle confrontational situations.
• Requires demonstrated ability in MS Office applications, in particular Excel and Access.
• Requires strong organizational skills.
• Requires strong interpersonal skills.
• Prefers strong analytical skills and the ability to interpret data and conduct root cause analysis.

Travel

• Travel as needed to support investigative activity within Company's service area.

Benefits

• Comprehensive health benefits (Medical/Dental/Vision).
• Retirement Plans.
• Generous PTO.
• Incentive Plans.
• Wellness Programs.
• Paid Volunteer Time Off.
• Tuition Reimbursement.

Salary Range

$70,500 - $94,395