Job Description

Job Description

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

The Nurse Investigator II is responsible for performing highly complex healthcare fraud investigations including but not limited to, complex surgical operations, inpatient hospital coding including diagnostic related grouping (DRG), and anesthesia cases. The incumbent is responsible for medical and coding oversight of medical records to ensure the appropriate CPT codes, diagnostic codes, and modifiers according to generally accepted medical coding guidelines, CPT; HCPCS; ICD-10 Guidelines; and CMS Correct Coding. The incumbent supports investigators related to Medical Procedures and CPT Coding issues and fraudulent activity. The incumbent will participate in settlement negotiations when they’ve provided assistance in performing medical and coding reviews. The Investigator is a Subject Matter Expert and may be subjected to being involved in litigation matters when medical procedures and CPT coding is an issue.

Responsibilities :

• Conducts large and highly complex healthcare fraud investigations worth tens of millions of dollars in potential fraud recoveries.
• Provides guidance and assistance to all investigators with regards to coding issues and investigations. The CPCII/Investigator III will be considered the subject matter expert.
• Conducts reviews and provides expertise on highly complex operative reports and medical records for the Pre-Payment review process.
• Performs ongoing and in depth CPC training to Special Investigation staff on coding changes, updates, and new requirements on CPT coding, IDC 10 and HCPC. They are responsible for developing and facilitating all CPT, IDC10 and HCPC training.
• Analyze and review confidential and highly sensitive investigative material/documents concerning employees, subscribers, providers and groups.
• Testifies during depositions and or in a court of law, as a subject matter expert witness.
• Exercise knowledge of CPT coding, ICD-9, ICD 10, HCPC and continues learning of new coding guidelines, updates and new requirements. Must meet the yearly requirements to maintain their certified professional coder designation.
• Participates in settlement negotiations with other investigators when providing assistance in performing coding reviews.

RN Addendum:

• Independently conducts complex medical reviews, provides assistance to other investigators in performing medical record reviews, and provides expertise on highly complex operative reports and medical records.
• Ability to analyze clinical records and independently perform medical record reviews from a clinical, medical coding and provider billing perspective to identify potential fraudulent behaviors.
• Communicates clinical medical record review findings in writing to investigators, senior leadership, legal, providers, members, outside counsel, law enforcement & regulatory agencies. Thorough documentation of medical record review findings in summaries, letters & presentations.
• Subject matter expert in investigative techniques and nursing.

Disclaimer:

This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Education/Experience:

• High School Diploma/GED required.
• Bachelor degree preferred or relevant experience in lieu of degree.
• 3 years’ experience utilizing claim processing and customer service systems required.
• 3+ years’ Nursing or medical coding experience.
• 5+ years’ experience in performing complex healthcare fraud investigations.

Additional licensing, certifications, registrations:

• Requires either a Certified Professional Coding Certificate or a Registered Nurse License.

Knowledge:

• Requires ability to conduct complex healthcare fraud investigations.
• Requires Medical Coding experience.
• Requires knowledge of health insurance operations (i.e. claims, enrollment, underwriting, etc.).
• Prefers specific knowledge of claims processing and customer service systems (NASCO adjustment and pend processing, UPS, UCSW, Research Station, Cognos, and Image).
• Prefer knowledge of ITS/Blue card process.
• Prefer knowledge in Microsoft products (Word, Excel, and Access).
• Requires ability to be deposed during litigation involving Special Investigation cases.

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 Excel and Access.
• Requires strong organizational skills.
• Requires strong interpersonal skills.
• Prefers strong analytical skills and the ability to interpret data and conduct root cause analysis.

Travel:

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

Salary Range:

$76,800 - $102,795

​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

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

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, 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. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

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