• New Jersey

Clinical Certified Professional Coder - Horizon Blue Cross Blue Shield of New Jersey

Job Summary:

This position is accountable for the review, interpretation and codification of Medical Policies and Legislative Mandates utilizing CPT-4, HCPC and ICD-9/ICD-10 coding parameters.


  • Reviews and interprets current Medical Policies for systematization.

  • Translates written policy 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.

  • Monitors State and CMS coding and coverage notifications and ensure internal tools, resources, systems and users are notified. Follow through and ensure all necessary changes are completed.

  • Using clinical skills, experiences and expertise identifies and determines appropriateness, inclusion and relevance of services and their codes as they pertain to a medical or payment policy and or initiative.

  • Performs functions to ensure integrity of resources and tools used by the Enterprise, for code set management, policies, mandates, clinical editing rules and benefit coding are maintained.

  • Monitor compliance of code use with policies and procedures relevant to clinical data and claim audits.

  • Apply knowledge of industry standard and established rules, regulations and guidelines of coding and billing practices for both professional and facility claims to respond to cross-departmental and LOB inquiries and needs. -Review, analyze, and audit claims across LOB to identify inappropriate billing practices, and or system configuration issues and follow through as needed to ensure changes are completed.

  • Prepare reports, charts and summaries for project presentation to internal stakeholders when applicable.

  • Provide expertise and guidance on proper billing and coding practices as they relate to benefit development, quality initiatives and application of specialized programs across the Enterprise.

  • Participate in new program initiatives, providing code identification, configuration parameters, BRD/TRD development, testing, and when applicable assist with drafting of payment policies.

  • Assist with the annual review of payment policies for Medicare and Medicaid LOB making changes as required with industry and coding changes.

  • Perform other related tasks as assigned.


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

  • Requires experience with physician and facility coding and billing of services

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

  • Requires knowledge of the health care delivery system

  • Prefer knowledge of state and federal laws and regulations, including CMS, DOBI and DMAHS requirements

Skills and Abilities:

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

  • Requires executive function and logic skills to troubleshoot configuration issues.

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

  • Demonstrated Excel conditional formatting, function usage, charting, Pivot tables and reporting skills.

  • 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.

  • Experience using CMS website for correct coding, billing manuals, NCD/LCD, articles and bulletins

  • Experience using New Jersey Medicaid website for billing, policies, bulletins and contract applicability.


  • Requires Bachelor's degree from an accredited college or university. Clinical medical background (RN, Foreign-trained medical school graduate) required.


  • 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 and databases.

Additional licensing, certifications, registrations:

  • Requires Licensed Registered Nurse or Foreign-trained medical school graduate.

  • 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).



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