CPC Investigator

Job not on LinkedIn

🕒 August 26

🦌 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 51%

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 with research and resolution of 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 analyze medical records 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 and other data to determine fraud or misrepresentation • Serve as primary contact for other Blue Plans on claim inquiries related to fraud investigations • Collect, collate, analyze and interpret data to conduct 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 non-fraud 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.) • Knowledge of medical coding, including CPT-4, HCPC, ICD-9/ICD-10 coding • Knowledge of medical terminology and anatomy & physiology related 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 in MS Office applications, particularly Excel and Access • Strong organizational skills • Strong interpersonal skills • Travel as needed to support investigative activity within Company's service area • Employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

🏖️ Benefits

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