The CPC Investigator performs reviews, audits, and coding oversight of medical records to ensure correct use of CPT, diagnosis, and modifier coding in accordance with accepted medical coding guidelines, CPT-4, HCPCS, ICD-10, and CMS correct coding rules.
This role also supports low-level investigations related to suspected fraudulent activity, including review of claims, enrollment, and accounting information. The position manages Special Investigations Unit pended claims, supports fraud resolution efforts, and helps ensure service levels are met for ASO accounts and Blue Card requirements.
Key responsibilities include reviewing suspended claims in the pre-payment process, gathering and interpreting documentation, analyzing sensitive investigative materials, and supporting internal and external stakeholders related to fraud investigations.
Required
- High school diploma or GED
- 2 years of experience in health insurance, quality chart audits, and/or utilization review
- 2–3 years of medical coding experience
- AAPC Certified Professional Coder (CPC) designation
- Knowledge of CPT-4, HCPCS, and ICD-9/ICD-10 coding
- Understanding of medical terminology, anatomy, physiology, and the health care delivery system
- Strong verbal and written communication skills
- Ability to handle confrontational situations effectively
- Strong organizational and interpersonal skills
- Proficiency with Microsoft Office applications, especially Excel and Access
Preferred
- Knowledge of health insurance operations such as claims, enrollment, and underwriting
- Familiarity with claims processing and customer service systems
- BlueCard / ITS knowledge
- Strong analytical skills and ability to conduct root cause analysis
Benefits
- Comprehensive medical, dental, and vision coverage
- Retirement plans
- Generous PTO
- Incentive plans
- Wellness programs
- Paid volunteer time off
- Tuition reimbursement
Location
Newark, New Jersey, US
Employment Type
Full-time
Experience Level
Intermediate Level
Salary Range
$70,500 - $94,395
Remote work allowed
No
Posted
1 month ago