CPC Investigator

About the Role The Certified Professional Coder (CPC) performs reviews, audits, and coding oversight of medical records, ensuring accurate CPT, HCPCS, ICD‑10 codes, and modifiers per industry and CMS guidelines. The CPC gathers, analyzes, and interprets documentation to conduct low‑level investigations, supports fraud research investigators, and manages Special Investigations Unit pended claims to meet service level agreements and Blue Card requirements. What You’ll Do Accurately review, audit, code, and analyze medical record documentation for claims that are suspended for Special Investigations pre‑payment processing. Apply ICD‑9/ICD‑10 CM coding guidelines to inpatient, outpatient, and professional medical services. Follow established procedures and utilize multiple systems and tools to conduct research. Assure timely, accurate, and efficient processing and resolution of pended claims and service requests. Analyze confidential investigative material and documents concerning employees, subscribers, providers, and groups. Obtain documentation such as claims forms, checks, medical records, utilization records, and specialized printouts to determine fraud or misrepresentation. Serve as the primary contact for other Blues Plans on claim inquiries related to fraud investigations. Collect, collate, analyze, and interpret data from internal and external sources for investigations. Handle subpoena requests and coordinate with law enforcement agencies and stakeholders. Investigate calls received on the Fraud Hotline, including provider and member outreach, medical records requests, and claims reviews. Route non‑fraud related hotline calls to the appropriate business unit. Education & Experience High School Diploma or GED required. Minimum 2years of experience in health‑insurance quality chart audits and/or utilization review. 2–3years of medical coding experience. Certified Professional Coder (CPC) designation required. Preferred: ITS/BlueCard knowledge and familiarity with claims processing and customer‑service systems (e.g., NASCO, UPS, UCSW, Cognos, ImagePlus). Skills & Qualifications In-depth knowledge of CPT, HCPCS, and ICD coding and medical terminology. Strong understanding of the health‑care delivery system, insurance operations, and claims processing. Proficiency with Microsoft Office, especially Excel and Access. Excellent verbal and written communication skills. Ability to handle confrontational situations effectively. Strong organizational, interpersonal, and analytical skills. Ability to conduct root cause analysis and interpret data. Travel Travel may be required to support investigative activity within the company’s service area. Compensation & Benefits Salary range: $70,500—$94,395. Benefits include comprehensive medical, dental, and vision coverage; retirement plans; generous paid time off; incentive plans; wellness programs; paid volunteer time off; and tuition reimbursement. Equal Opportunity Employer 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, disability, or any other protected class as required by law. Horizon will provide reasonable accommodations upon request. #J-18808-Ljbffr