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 :
RN Addendum:
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:
Additional licensing, certifications, registrations:
Knowledge:
Skills and Abilities:
Travel:
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:
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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