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

The Senior Professional Coder provides services to perform code abstraction using the Official Coding Guidelines for ICD-9-CM/ICD-10-CM, AHA Coding Clinic Guidance, and in accordance with all state and federal regulations and internal policies and procedures. HCC Risk Adjustment Coders will be involved with activities of code abstraction for the following programs; including but not limited to, Commercial Risk Adjustment/IVA (Initial Validation Audit), Medicare Advantage Risk Adjustment/RADV Audit (Risk Adjustment Data Validation). HCC Risk Adjustment Coders are required to maintain a minimum 95% accuracy rating on coding quality audits.

What You'll Do

• Compile chart review findings statistics, analyze data results and implement meaningful action plans that improve providers’ performance levels.
• Educate new staff to produce and maintain high quality data abstraction and chart reviews.
• Develop quality assurance processes to ensure data integrity of all submitted diagnoses to regulatory agencies and key stakeholders.
• Evaluate and improve the effectiveness of risk adjustment coding programs, policies & procedures and workflow.
• Work closely with inter-departmental team management to support coding initiatives related to risk adjustment programs.
• As a Subject Matter Expert, this person will support risk adjustment coding initiatives to identify opportunities to enhance and grow business.
• Responsible for educating and keeping management informed on current changes in regulations/guidance related to ICD-10 coding and quality documentation and reporting.
• Interface with operations and clinical leadership to assist in identification of coding & documentation improvements and promote best practices.
• Conduct mock audits or surveillance activities that target problematic diagnoses as identified by CMS and internal stakeholders.
• Understand and translate CPT, HCPC, ICD-9/ICD-10 codes for HCC abstraction.
• Review medical records for completeness, accuracy and compliance with applicable coding guidelines and regulations.
• Maintains department productivity and accuracy standards.

What You Bring

Education/Experience:

• Requires current Registered Health Information Technologies (RHIT) or a certification and in good standing by a nationally recognized accrediting agency (e.g., American Academy of Professional Coders (AAPC) or American Health Information Management (AHIMA))
• Requires 5+ years of Medical Coding experience
• Requires a minimum of 5+ years’ experience in Health Insurance/quality chart audits and/or Utilization Review
• Bachelor's degree required

Knowledge:

• Requires proficiency in the CPT-4, HCPC, ICD-9/ICD-10 coding
• Requires knowledge of medical terminology and anatomy & physiology related to medical procedures, abbreviations and terms
• Requires knowledge of the health care delivery system

Skills/Abilities:

• Requires the ability to utilize a personal computer and applicable software (e.g. proficiency in Word and Excel)
• Must have effective verbal and written communication skills and demonstrate the ability to work well within a team
• 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 problem solving skills
• Proven ability to ask probing questions and obtain thorough and relevant information

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.