Investigator II

Horizon Blue Cross Blue Shield of New Jersey; United States; Remote; USD 62,000 - 84,000; Full time

Job summary

Horizon Blue Cross Blue Shield of New Jersey seeks a Senior Investigator to lead analytical activities related to claims fraud. This role requires a Bachelor's degree and relevant experience, focusing on detecting fraudulent activities and managing investigations effectively. The ideal candidate will have expertise in health insurance operations and strong communication skills. Join us in maintaining the integrity of our operations and serving our community.

Benefits

Comprehensive health benefits (Medical/Dental/Vision)

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Qualifications

• Minimum 2 years claims, customer service, or relevant law enforcement experience required.
• AHFI, CFE, or CPC certifications preferred.
• In-depth knowledge of health insurance operations required.

Responsibilities

• Detect fraudulent activities by subscribers, providers, and other parties.
• Prepare and document fraud cases for potential prosecution.
• Conduct investigations with minimal supervision.

Skills

Excellent verbal and written communication

Ability to handle confrontational situations

Organizational skills

Conduct interviews/interrogations

Create and interpret databases

Education

Bachelor's Degree

Tools

MS Office (Excel, Access)

Job description

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.

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. This is a senior level investigator expected to conduct and resolve investigations and manage their case load with limited management/supervisor oversight.

• Detects fraudulent activities by subscribers, providers, groups, employees and other parties.
• Decides the most efficient and effective method of investigation appropriate for each individual case.
• 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 agnecies 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.
• Up to date and Knowledgeable about all applicable fraud statutes; Local, state and federal to ensure duties and assignments are carried out within the requirement of applicable law and local office expectations.
• Additional personal and professional attributes that are critical to successful performance:

Education/Experience:

• Bachelors Degree Required
• Minimum 2 yrs claims, customer service or relevant law enforcement experience required.
• ITS/Blue Card knowledge preferred

Additional licensing, certifications, registrations:

• AHFI, CFE, or CPC certifications preferred
• Prefers licensing in medical field.
• Will consider advanced degree in liu of certifcation.

Knowledge:

• Requires in depth knowledge of health insurance operations (i.e. claims, enrollment, underwriting, etc.)
• Prefers working knowledge of NJ Criminal and Civil Law relative to health insurance fraud.
• Prefers working knowledge of investigative process

Skills and Abilities:

• Requires excellent verbal and written communication skills.
• Requires the ability to effectively handle and defuse confrontational situations.
• Requires demonstrated ability in MS Office applications, in particular Excel and Access.
• Requires strong organizational skills.
• Requires demonstrated ability to conduct interviews/interrogations.
• Requires the ability to create and interpret databases using multiple software applications.

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

Salary Range:

$62,100 - $83,160

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:
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.