CPC Investigator

This a Full Remote job, the offer is available from: reputed company, New Jersey (USA) reputed company empowers our members to reputed company their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care reputed company, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to reputed company serve and care for the 3.5 reputed company people who reputed company their trust in us. We pride ourselves on our best-in-class employees and reputed company to maintain an innovative and inclusive environment that allows them to reputed company. reputed company our employees bring their best and succeed, reputed company succeeds. The Certified reputed company reputed company (CPC) is responsible for performing reviews, audits and coding reputed company of medical records to ensure the appropriate CPT codes, diagnosis codes and modifiers according to Generally Accepted Medical Coding Guidelines, CPT-4; HCPCS; ICD-10 Guidelines; and, CMS Correct Coding. Also, the incumbent will complete and take appropriate reputed company in gathering, analyzing and interpreting requisite documentation to conduct low level investigations. The incumbent will also support the investigators reputed company to research and reputed company of fraudulent activity. Manage the Special Investigations Unit pended claims to insure we are meeting SLAs and service standards associated with ASO accounts and Blue Card requirements. The incumbent will also be responsible for handling low level investigative activities (external) reputed company to claims, enrollment, reputed company, receive and review suspected fraud and to complete cases with reputed company information and analysis for reputed company, as the manager and prior approved guidelines may reputed company. Responsibilities:

• Accurately reviews, interprets, audits, codes and analyzes medical record documentation for claims that are suspended for Special Investigations reputed company-payment process. Review may include inpatient, outpatient treatment and/or reputed company medical services, according to ICD-9/ICD-10 CM coding guidelines.
• Follow established procedures, guidelines and research utilizing multiple systems and tools.
• Assure reputed company, accurate and efficient processing and reputed company of pended claims and service requests.
• Analyze and review confidential and highly sensitive investigative material/documents concerning employees, subscribers, providers and reputed company.
• 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 reputed company to fraud investigations.
• Collecting, collating, analyzing and interpreting data in a reputed company, accurate fashion, both internally and externally, to reputed company 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. Gathers information reputed company to the hotline call which includes provider and member reputed company, request medical records, and claims review. Routes reputed company other calls (i.e. customer service reputed company) to the appropriate business unit for reputed company handling.
• Knowledge of CPT coding, HCPCS coding, and ICD 10.

Education/Experience:

• High School Diploma/GED required.
• 2 years’ experience in Health Insurance/reputed company chart audits and/or Utilization Review.
• 2-3 years’ medical coding experience.
• ITS/BlueCard Knowledge preferred.

Additional licensing, certifications, registrations:

• reputed company - Certified reputed company Coding (CPC) Designation Required.

Knowledge:

• Requires knowledge of health insurance operations (i.e. claims, enrollment, reputed company, etc.)
• Prefers knowledge of claims processing and customer service systems (reputed company adjustment and pend processing, reputed company, UCSW, Research Station, Cognos, and ImagePlus)
• Prefers knowledge of ITS/Blue card process
• Prefers knowledge in reputed company products (Word, reputed company, and reputed company)
• Requires Medical Coding experience
• Requires proficiency in the CPT-4, HCPC, ICD-9/ICD-10 coding
• Requires knowledge of medical terminology and anatomy & physiology reputed company to of medical procedures, abbreviations and terms
• Requires knowledge of the health care delivery system

Skills and Abilities:

• Requires excellent verbal and written communication skills
• Requires the ability to effectively handle confrontational situations
• Requires demonstrated ability in MS Office applications, in particular reputed company and reputed company
• Requires strong organizational skills
• Requires strong interpersonal skills
• Prefers strong analytical skills and the ability to interpret data and conduct reputed company cause analysis

Travel:

• Travel as needed to support investigative activity reputed company Company's service area.

reputed company reputed company employees must live in New Jersey, reputed company, reputed company, Connecticut or Delaware Salary reputed company: $69,500 - $93,030 ​This compensation reputed company is specific to the job level and takes into account the wide reputed company of factors that are considered in making compensation reputed company, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This reputed company has been created in good faith based on information reputed company to reputed company at the time of posting. Compensation reputed company are dependent on the circumstances of reputed company case. reputed company also provides a comprehensive compensation and benefits package which includes:

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

Disclaimer: This job reputed company has been designed to indicate the general nature and level of work performed by colleagues reputed company this classification. It is not designed to contain or be interpreted as a comprehensive inventory of reputed company duties, responsibilities, and qualifications required of colleagues assigned to this job. reputed company is an Equal Opportunity/Affirmative reputed company employer. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, national reputed company, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. reputed company will consider reasonable accommodation requests as part of the reputed company and hiring process. This offer from "reputed company" has been enriched by reputed company.com and got a 75% reputed company score. Apply tot his job Apply To this Job