[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.

• Manage the Special Investigations Unit pended claims to ensure compliance with SLAs and service standards associated with ASO accounts and Blue Card requirements.
• Handle low level investigative activities related to claims, enrollment, accounting, and suspected fraud.
• Complete cases with all information and analysis for resolution as directed by management.

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.
• AAPC - Certified Professional Coding (CPC) Designation Required.

Requirements

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

Benefits

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

Company Description

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us.