CPC Investigator

This is a fully remote position, open to applicants in New Jersey.

📋 Description

• Conduct thorough reviews, interpretations, audits, coding, and analysis of medical record documentation for claims that are flagged for Special Investigations pre-payment processes.

• Reviews may encompass inpatient, outpatient treatments, and/or professional medical services, adhering to ICD-9/ICD-10 CM coding standards.

• Follow established protocols and guidelines while utilizing various systems and tools for research.

• Ensure the timely, precise, and efficient processing and resolution of pending claims and service requests.

• Analyze and assess confidential and highly sensitive investigative materials/documents concerning employees, subscribers, providers, and groups.

• Acquire necessary documentation, claims forms, checks, medical records, utilization records, specialized printouts, and other data to ascertain the presence of fraud or misrepresentation in claims submissions.

• Serve as the primary contact for other Blues Plans regarding any claim inquiries related to fraud investigations.

• Collect, compile, analyze, and interpret data promptly and accurately to gather the essential documentation required for conducting investigations.

• Personally manage subpoena requests and coordinate efforts with law enforcement, state agencies, and claims stakeholders.

• Investigate calls received on the Fraud Hotline that present legitimate allegations of fraud.

⛳️ Requirements

• High School Diploma/GED is mandatory.

• Minimum of 2 years’ experience in Health Insurance/quality chart audits and/or Utilization Review.

• 2-3 years’ experience in medical coding is required.

• AAPC - Certified Professional Coding (CPC) designation is essential.

• Familiarity with health insurance operations (such as claims, enrollment, underwriting, etc.) is necessary.

• Preferred knowledge of claims processing and customer service systems (including NASCO adjustment and pend processing, UPS, UCSW, Research Station, Cognos, and ImagePlus).

• Preference for knowledge of the ITS/Blue card process.

• Proficiency in Microsoft products (Word, Excel, and Access) is preferred.

• Requires expertise in CPT-4, HCPC, ICD-9/ICD-10 coding.

• Must possess knowledge of medical terminology and anatomy & physiology relevant to medical procedures, abbreviations, and terms.

🏝️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision).

• Retirement plans.

• Generous paid time off (PTO).

• Incentive plans.

• Wellness programs.

• Paid Volunteer Time Off.

• Tuition reimbursement.