Medical Investigator Claims

Horizon Blue Cross Blue Shield of New Jersey; Connecticut; On-site; USD 63,000 - 84,000; Full time

Benefits offered by this job

Comprehensive health benefits (Medical

Retirement Plans

Tuition Reimbursement

Job summary

Horizon Blue Cross Blue Shield of New Jersey is seeking a fraud investigations manager to lead analytical activities related to claims, enrollment and operations for detecting and resolving suspected fraud. This role coordinates with law enforcement and claims stakeholders and prepares cases with supporting evidence.

You will update the FEP SIU Tracking System, handle the fraud hotline, travel as needed, and testify in legal proceedings when required.

Qualifications

• High School Diploma or GED is required.
• Minimum 2 years claims, customer service or related law enforcement experience.
• Basic knowledge of health insurance operations (claims, enrollment, underwriting).
• Familiarity with SIU health insurance operations is preferred.
• Proven ability using MS Office applications, especially Excel and Access.

Responsibilities

• Lead analytical and investigative activities related to fraud prevention across claims and enrollment.
• Prepare and document fraud cases with evidence for potential prosecution or civil litigation.
• Conduct field investigations and coordinate with law enforcement and claims stakeholders.
• Represent the company in legal proceedings as required in fraud cases.
• Update and track the FEP SIU Tracking System (FSTS) with case activity, subpoenas, audits, referrals and convictions.
• Manage calls from the Fraud hotline impacting the FEP program; travel as needed.

Skills

Claims experience

Customer service experience

Law enforcement experience

Education

High School Diploma/GED

Tools

Excel

Access

MS Office

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. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us.

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.

Prepares and documents fraud cases, assembling evidence for potential prosecution or civil litigation.

Personally handles field investigation work; and coordinates efforts with law enforcement state agencies and claims stakeholders.

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.

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.

Manages all calls from the Fraud hotline that impact the FEP program.

High School Diploma/GED required.

Minimum 2 yrs claims, customer service or relevant law enforcement experience required.

Requires basic knowledge of health insurance operations (i.e. claims, enrollment, underwriting, etc.).

Requires basic knowledge of SIU health insurance operations.

Requires demonstrated ability in MS Office applications, in particular Excel and Access.

Travel:

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

We believe that when our people thrive, our communities do too.

63,000 - $84,420This 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.

Comprehensive health benefits (Medical/Dental/Vision)

Retirement Plans

Tuition Reimbursement

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