Medical Claims Fraud Investigation Manager

Horizon Blue Cross Blue Shield of New Jersey; East Windsor Hill (CT); On-site; USD 63,000 - 84,000; Full time

Benefits offered by this job

Comprehensive health benefits

Retirement Plans

Tuition Reimbursement

Job summary

Horizon Blue Cross Blue Shield of New Jersey is seeking an investigator to lead analytical and field-based fraud activities within our SIU program. You will handle claims, enrollment, and related operations to detect fraud, prepare cases, and coordinate with law enforcement when needed.

The role requires basic health insurance operations knowledge, strong MS Office skills, and willingness to travel as necessary.

Qualifications

• Requires basic knowledge of health insurance operations (i.e. claims, enrollment, underwriting).
• Requires basic knowledge of SIU health insurance operations.
• Demonstrated ability in MS Office applications, particularly Excel and Access.

Responsibilities

• Accountable for analytical and investigative activities related to claims, enrollment, accounting and other operations to detect fraud.
• Prepares and documents fraud cases, assembling evidence for potential prosecution or civil litigation.
• Personally handles field investigation work; coordinates efforts with law enforcement state agencies and claims stakeholders.
• Updates and tracks the FEP SIU Tracking System (FSTS) with case activity, subpoenas, financial information, audits, referrals and convictions.
• Manages all calls from the Fraud hotline that impact the FEP program.
• Travel: ~ Travel as needed to support investigative activity within Company's service area.

Skills

MS Excel

MS Access

Health insurance basics

Education

High School Diploma/GED

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking an investigator to lead analytical and field-based fraud activities within our SIU program. You will handle claims, enrollment, and related operations to detect fraud, prepare cases, and coordinate with law enforcement when needed.

The role requires basic health insurance operations knowledge, strong MS Office skills, and willingness to travel as necessary.