CPC Investigator

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 RoleThe 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 DoAccurately 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 BringEducation/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 experienceRequires proficiency in the CPT-4, HCPC, ICD-9/ICD-10 codingRequires knowledge of medical terminology and anatomy & physiology related to of medical procedures, abbreviations and termsRequires knowledge of the health care delivery systemSkills and Abilities:Requires excellent verbal and written communication skillsRequires the ability to effectively handle confrontational situationsRequires demonstrated ability in MS Office applications, in particular Excel and AccessRequires strong organizational skillsRequires strong interpersonal skillsPrefers strong analytical skills and the ability to interpret data and conduct root cause analysisTravel:Travel as needed to support investigative activity within Company's service area.Why Horizon?At Horizon, you’ll do meaningful