CPC Investigator

Job not on LinkedIn

🕒 May 30

🏖️ New Jersey – Remote

🏖️ New Jersey – Remote

💵 $70.5k - $94.4k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

✨ Investigator

🚫👨‍🎓 No degree required

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NJM Insurance Group

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1913

Insurance

NJM Insurance Group is a well-established insurance provider offering a range of personal and commercial insurance products. Their services include auto, homeowners, renters, condo, commercial auto, and business insurance, with a focus on exceptional customer satisfaction and claims experience. NJM is recognized for its outstanding auto claims experience by J. D. Power and is committed to serving customers in states like Connecticut, Maryland, New Jersey, Ohio, and Pennsylvania. The company prides itself on being straightforward and customer-focused, without jingles or mascots, offering trusted insurance solutions and multiple discount opportunities for various policies.

📋 Description

• 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 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.

🎯 Requirements

• 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. • 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 proficiency in the CPT-4, HCPC, ICD-9/ICD-10 coding • Requires knowledge of medical terminology and anatomy & physiology related to medical procedures, abbreviations and terms

🏖️ Benefits

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