Healthcare Coding & Fraud Investigator (CPC)

Horizon Blue Cross Blue Shield of New Jersey; Newark (NJ); On-site; USD 71,000 - 94,000; Full time

Benefits offered by this job

Healthcare benefits

Retirement Plans

Generous PTO

Tuition Reimbursement

Job summary

Horizon Blue Cross Blue Shield of New Jersey is seeking a Certified Professional Coder (CPC) to perform reviews, audits, and coding oversight of medical records, ensuring accurate CPT/HCPCS/ICD-10 coding in line with guidelines and CMS requirements.

The role supports fraud investigations, manages pended claims, and collaborates with law enforcement and stakeholders to resolve cases while meeting SLAs and Blue Card requirements.

Qualifications

• 2 years’ experience in Health Insurance/quality chart audits and/or Utilization Review.
• 2-3 years’ medical coding experience.
• AAPC CPC Certification required.
• Knowledge of CPT coding, HCPCS and ICD-10.

Responsibilities

• Review, audit and code medical records for claims and investigations.
• Assist in fraud investigations and analyze confidential material.
• Handle pended claims to meet SLAs and Blue Card requirements.
• Coordinate data collection and interpretation for investigations.
• Act as primary contact for related claim inquiries with Blues Plans.

Skills

Medical coding

CPT/HCPCS/ICD-10

MS Excel/Access

Verbal & written communication

Analytical skills

Education

AAPC CPC Certification

Tools

NASCO

Research Station

Cognos

ImagePlus

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking a Certified Professional Coder (CPC) to perform reviews, audits, and coding oversight of medical records, ensuring accurate CPT/HCPCS/ICD-10 coding in line with guidelines and CMS requirements.

The role supports fraud investigations, manages pended claims, and collaborates with law enforcement and stakeholders to resolve cases while meeting SLAs and Blue Card requirements.