CPC Investigator

Certified Professional Coder

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. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.

About the Role

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. Also, the incumbent will complete and take appropriate action in gathering, analyzing and interpreting requisite documentation to conduct low level investigations. The incumbent will also support the investigators related to research and resolution of fraudulent activity. Manage the Special Investigations Unit pended claims to insure we are meeting SLAs and service standards associated with ASO accounts and Blue Card requirements. The incumbent will also be responsible for handling low level investigative activities (external) related to claims, enrollment, accounting, receive and review suspected fraud and to complete cases with all information and analysis for resolution, as the manager and prior approved guidelines may direct.

What You'll Do

• Accurately reviews, interprets, audits, codes and analyzes medical record documentation for claims that are suspended for Special Investigations pre-payment process. Review may include inpatient, outpatient treatment and/or professional medical services, according to ICD-9/ICD-10 CM coding guidelines.
• 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. Gathers information related to the hotline call which includes provider and member outreach, request medical records, and claims review. Routes all other calls (i.e. customer service related) to the appropriate business unit for proper handling.
• Knowledge of CPT coding, HCPCS coding, and ICD 10.

What You Bring

Education/Experience:

• 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.

Additional licensing, certifications, registrations:

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

Knowledge:

• 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 of 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.

Why Horizon?

At Horizon, you'll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we'd love to hear from you!

Salary Range: $70,500 - $94,395

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

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

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.