Investigator II

100 Horizon Healthcare Services, Inc; Newark (NJ); Sur place; USD 63 000 - 84 000; Plein temps

Avantages offerts par ce poste

Comprehensive health benefits (Medical

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Résumé du poste

Horizon Blue Cross Blue Shield of New Jersey is seeking an Investigator II to lead analytical and investigative activities related to claims, enrollment, and other operations to detect fraud and complete cases with thorough analysis for resolution. The role involves preparing and documenting fraud cases, coordinating with law enforcement, and testifying when required.

You will manage FEHB-related investigations, track case activity in the FSTS system, and handle calls from the fraud hotline

Qualifications

• High School Diploma/GED required.
• Minimum 2 yrs claims, customer service or relevant law enforcement experience required.
• ITS/Blue Card knowledge preferred.
• Knowledge of health insurance operations is required.

Responsabilités

• Prepares and documents fraud cases, assembling evidence for potential prosecution or civil litigation.
• Provides evidence and/or testifies in cases where law enforcement pursue prosecution.
• Handles field investigation work and coordinates with law enforcement and claims stakeholders.
• Represents the Company in complex and potentially multi-million dollar settlement negotiations with attorneys.
• Testifies in legal proceedings as required in fraud cases.
• Manages calls from the Fraud hotline that impact the FEP program and updates related tracking systems.

Connaissances

Verbal communication

Written communication

Customer service

Confrontation handling

MS Office

Formation

High School Diploma/GED

Outils

Excel

Access

MS Office

Description du poste

About the Role

This position is accountable for analytical and investigative activities (external and internal) related to claims, enrollment, accounting and other operations to detect, receive and review suspected fraud and to complete cases with all information and analysis for resolution, as the manager and prior approved guidelines may direct.

What You Do

Prepares and documents fraud cases, assembling evidence for potential prosecution or civil litigation. Provides evidence and/or testifies in cases where law enforcement agencies pursue prosecution. Personally handles field investigation work; and coordinates efforts with law enforcement state agencies and claims stakeholders. Represents the Company in conducting complex and potentially multi-million dollar settlement negotiations with attorneys and/or other responsible parties (representing providers, enrolled groups and individual subscribers). Serves as Company's representative in testifying in legal proceedings as required in fraud cases. Additional personal and professional attributes that are critical to successful performance. The Investigator II for the FEP LOB will complete the tasks listed above in addition to the following: Follow established procedures and guidelines outlined in the latest Federal Employee Health Benefits (FEHB) Carrier Letter. Investigate cases that impact the FEP LOB, as well as handling all investigations regarding FEP eligibility. Updating and tracking the FEP SIU Tracking System (FSTS) with case activity, subpoenas, financial information, audits, referrals, settlements and convictions of cases impacting the FEP. Interfaces with the BCBSA FEP SIU Consultant. Manages all calls from the Fraud hotline that impact the FEP program.

What You Bring

Education/Experience: High School Diploma/GED required. Minimum 2 yrs claims, customer service or relevant law enforcement experience required. ITS/Blue Card knowledge preferred. Knowledge: Requires basic knowledge of health insurance operations (i.e. claims, enrollment, underwriting, etc.). Requires basic knowledge of SIU health insurance operations. Skills and Abilities: Requires excellent verbal and written communication skills. Requires the ability to effectively handle confrontational situations. Requires demonstrated ability in MS Office applications, in particular Excel and Access. Requires strong organizational skills.

Travel

Travel as needed to support investigative activity within Company's service area.

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.

Salary Range:

$63,000 - $84,420

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.

Benefits

• 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.

Equal Opportunity

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.

About Us

We are the leading health insurer in New Jersey, trusted by generations of families and businesses. We are dedicated to enriching the lives and health of our members and the New Jersey communities we serve, because we live and work here too.

Our Mission

We empower our members to achieve their best health.

Our Vision

We are New Jersey’s health solutions leader driving innovations that improve health care quality, affordability and member experience in the markets we serve.