Certified Professional Coder

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

Job Summary:

• Reviews and interprets current Medical Policies for systematization.

• Translates written policy interpretation into CPT, HCPC, ICD-9/ICD-10 codes for input into systems.

• Translates Legislative Mandates into CPT, HCPC, ICD-9/ICD-10 codes for input into systems.

• Maintains a database for all policies and mandates that is updated each time new/revised/deleted CPT/HCPC/ICD-9/ICD-10 are released.

• Monitor compliance with policies and procedures relevant to clinical data reviewed.

• Perform updates to the criteria file to include adds/deletes/revisions of CPT-4 and HCPC codes. Review all codes for accuracy; review database to criteria file before implementation of policy.

• Handle internal and external areas requests to investigate current state and historical of changes made to a particular CPT-4/HCPC/Diagnosis code such as effective dates, messages used, parameter limitations.

• Review and analyze BRD/TRD/Summary to ensure accuracy of implementation of policies.

• Review of scripts concerning Edits in criteria file. Review logic concerning implementation of policies.

• Assist benefit file on criteria loading to best accommodate implementation of benefits.

• Ensure files (provider/criteria) are loaded correctly in order to receive proper Edits 405/406.

• Perform other related tasks as assigned.

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.

• High School Diploma/GED required.

• Bachelor degree preferred or relevant experience in lieu of degree.

• Clinical medical background (RN, Foreign-trained medical school graduate) preferred.

• Requires 3 - 5 years of Medical Coding experience.

• Requires a minimum of 2 years experience in Health Insurance/Claims Processing and/or Utilization Review.

• Prefer knowledge/experience with computer processing systems.

• Requires current Registered Health Information Technologies (RHIT) or Certified Professional Coder designation from the American Academy of Professional Coders or a Certified Coding Specialist , P from the American Health Information Management (AHIMA).

Knowledge:

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

• Requires knowledge of anatomy, physiology and medical terminology of medical procedures, abbreviations and terms.

• Requires knowledge of the health care delivery system.

• Requires the ability to utilize a personal computer and applicable software ( e.g. proficiency in Word, Excel, Access ).

• Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.

• Demonstrated ability to deliver highly clinical information to technical individuals.

• Must demonstrate professional and ethical business practices, adherence to company standards and a commitment to personal and professional development.

• Proven ability to exercise sound judgment and strong problem solving skills.

• Proven ability to ask probing questions and obtain thorough and relevant information.

• Must have the ability to organize/prioritize/analyze complex tasks.

• Use of CMS website for CCI rules and regulations.

• Use of other approved websites for research.

Salary Range:

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.