Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health.  For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. 

About the Role

This position is responsible for being the lead on site audits of hospital billing and coding practices and desk audits; forms development, profiling and tracking institutional audit trends. Designing audit protocols and special projects. Performs and finalizes multiple per diem, bill verification, DRG Validation (utilization review audits) and credit balance. Additionally provides guidance/instruction to various stakeholders on ICD10-CM, ICD10-PCS & DRG assignment payment and auditing.

What You'll Do

• Identifies and presents billing discrepancies found during audit and coordinates referral of improper claim payments through the appropriate channels.

• Identifies error trends as they relate to medical record and or billing documentation or misinterpretation of provider contract stipulations.

• Compiles statistics and other audit information to present to accounts, regulatory agencies, internal requesters.

• Reviews and updates audit processes with manager for purposes of keeping up with new innovations in clinical data review and company cost containment initiatives.

• Required to train new staff on department/audit procedures.

• Performs other special assignments as requested by manager.

• Demonstrates knowledge, understanding and conforms to laws, regulations and policies that pertain to the organizational units business.

What You Bring

Education/Experience:

• High School Diploma/GED required.

• Bachelor degree in Health Information Management preferred or relevant experience in lieu of degree.

• Requires a minimum of 3 years experience in a medical records department of an acute care hospital or other health care facility.

• Experience with DRG validation, ICD-10-CM training and education.

Additional licensing, certifications, registrations:

• RHIT/RHIA certification OR RN with CCS

Knowledge:

• Requires knowledge of medical terminology, detailed knowledge of anatomy & physiology, disease pathogenesis and treatment including procedural drug therapies, ancillary and diagnostic services.

• Requires knowledge of principles of utilization management.

• Requires knowledge of hospital structures and payment systems.

• Requires knowledge of centers of Medicare and Medicaid prospective payment system regulations.

• Prefer knowledge of ACCESS Software.

Skills and Abilities:

• Must have effective verbal and written communication skills and demonstrate the ability to work well within a team. Demonstrated ability to deliver highly technical information to less technical individuals.

• Must have strong PC skills experience with MICROSOFT office programs: excel, word and power point.

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

• Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required. Demonstrated ability to work in a production focused environment.

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

• Needs to demonstrate willingness to cross-train, and be cross-trained, in other roles/duties.

• Must be detail oriented with strong organizational and data processing skills. Proven ability to follow detailed instructions is essential, along with proven problem solving skills.

• Proven analytical, research and problem solving skills a must.

Why Horizon?

At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth.  We believe that when our people thrive, our communities do too.  If you are passionate about making an impact, we’d love to hear from you!

Salary Range:

$79,100 - $105,945

​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

Disclaimer:

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

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.