CPC Investigator

Job not on LinkedIn

🔥 0 minutes ago

🦌 Connecticut, New Jersey, +2 more states – Remote

🦌 Connecticut – Remote 🏖️ New Jersey – Remote 🗽 New York – Remote 🔔 Pennsylvania – Remote

💵 $70.5k - $94.4k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🚫👨‍🎓 No degree required

👻 Ghost score 16%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Horizon Connect @ Wall BCBSNJ

WebsiteLinkedInAll Job Openings

2 - 10 employees

⚕️ Healthcare Insurance

🏥 Healthcare

Healthcare Insurance • Healthcare

Horizon Connect @ Wall BCBSNJ is a LinkedIn presence or local program/office associated with Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ). Based on the name and context, it appears to be connected to Horizon BCBSNJ’s health insurance operations and local outreach or member/provider engagement in the Wall, NJ area. Publicly available information provided is limited and mostly LinkedIn site chrome rather than a company profile, so this description is conservative and based on the affiliation indicated by the name.

📋 Description

• Perform reviews, audits and coding oversight of medical records to ensure appropriate CPT codes, diagnosis codes and modifiers. • Gather, analyze and interpret documentation to conduct low-level investigations. • Support investigators in researching and resolving fraudulent activity. • Manage Special Investigations Unit pended claims to meet SLAs and service standards for ASO accounts and Blue Card requirements. • Handle low-level external investigative activities related to claims, enrollment and accounting. • Review and resolve suspected fraud cases with complete information and analysis. • Review, interpret, audit, code and analyze medical record documentation for claims suspended in the Special Investigations pre-payment process. • Follow established procedures, guidelines and research using multiple systems and tools. • Process and resolve pended claims and service requests accurately and efficiently. • Analyze confidential investigative materials concerning employees, subscribers, providers and groups. • Obtain documentation, claims forms, checks, medical records, utilization records, specialized printouts and other data to determine fraud or misrepresentation. • Serve as primary contact for other Blue Plans regarding claim inquiries related to fraud investigations. • Collect, collate, analyze and interpret internal and external data for investigations. • Handle subpoena requests and coordinate with law enforcement state agencies and claims stakeholders. • Investigate legitimate Fraud Hotline allegations, conduct provider and member outreach, request medical records and review claims; route other calls to the appropriate business unit.

🎯 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.). • 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 medical procedures, abbreviations and terms. • Requires knowledge of the health care delivery system. • 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. • Employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. • Travel as needed to support investigative activity within Company's service area.

🏖️ Benefits

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