CPC Investigator

Horizon Blue Cross Blue Shield of New Jersey•Newark, NJ

23h•$70,500 - $94,395

About The Position

The Certified Professional Coder (CPC) performs medical-record reviews, audits, coding oversight, and low-level investigations to support the Special Investigations Unit. The role ensures that CPT, diagnosis, and modifier coding follows applicable generally accepted coding guidelines, CPT-4, HCPCS, ICD-10, and CMS Correct Coding requirements. The investigator gathers, analyzes, and interprets documentation, supports investigation and resolution of suspected fraud, and manages pended claims to meet service-level agreements and service standards for ASO accounts and Blue Card requirements. The role handles low-level external investigative activity involving claims, enrollment, and accounting; reviews suspected fraud; and completes cases with relevant information and analysis for resolution as directed by the manager and approved guidelines. Work includes handling sensitive investigative materials, coordinating with other Blue Plans and law enforcement or state agencies, and responding to legitimate Fraud Hotline allegations. Travel may be needed to support investigative activity within the Company’s service area. Employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Requirements

High school diploma or GED.
Two years of experience in health insurance, quality chart audits, and/or utilization review.
Two to three years of medical coding experience.
AAPC Certified Professional Coder (CPC) designation.
Knowledge of health insurance operations, including claims, enrollment, and underwriting.
Medical coding experience and proficiency in CPT-4, HCPCS, and ICD-9/ICD-10 coding.
Knowledge of medical terminology, anatomy and physiology relevant to medical procedures, abbreviations, and terms.
Knowledge of the health care delivery system.
Excellent verbal and written communication skills.
Ability to effectively handle confrontational situations.
Demonstrated ability with Microsoft Office applications, particularly Excel and Access.
Strong organizational and interpersonal skills.
Must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Nice To Haves

ITS/BlueCard knowledge.
Knowledge of claims processing and customer service systems, including NASCO adjustment and pend processing, UPS, UCSW, Research Station, Cognos, and ImagePlus.
Knowledge of the ITS/Blue Card process.
Knowledge of Microsoft Word, Excel, and Access.
Strong analytical skills and ability to interpret data and conduct root cause analysis.

Responsibilities

Review, interpret, audit, code, and analyze medical-record documentation for claims suspended in the Special Investigations pre-payment process, including inpatient, outpatient, and professional medical services.
Follow established procedures and guidelines, and conduct research using multiple systems and tools.
Ensure timely, accurate, and efficient processing and resolution of pended claims and service requests.
Analyze and review confidential, highly sensitive investigative materials concerning employees, subscribers, providers, and groups.
Obtain documentation, claims forms, checks, medical records, utilization records, specialized printouts, and other data needed to determine whether claims submissions involve fraud or misrepresentation.
Serve as the primary contact for other Blue Plans regarding claim inquiries related to fraud investigations.
Collect, collate, analyze, and interpret internal and external data and gather documentation needed to conduct investigations.
Handle subpoena requests and coordinate with law enforcement, state agencies, and claims stakeholders.
Investigate legitimate allegations received through the Fraud Hotline, including provider and member outreach, medical-record requests, and claims review; route other calls to the appropriate business unit.
Travel as needed to support investigative activity within the Company's service area.