Supv, FEP Investigations

100 Horizon Healthcare Services, Inc; Newark (NJ); On-site; USD 87,000 - 119,000; Full time

Benefits offered by this job

Comprehensive health benefits

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Job summary

Horizon Blue Cross Blue Shield of New Jersey seeks a senior leader to manage the SIU Team within the Special Investigations Unit for the Federal Employee Program. You will supervise investigators, prioritize cases, and guide efficient, compliant investigations.

You will coordinate settlements with the SIU Manager/Director, engage with law enforcement and regulatory bodies, and represent the company in legal settings. Strong communication, interviewing, and analytical skills are essential.

Qualifications

• Requires BA in criminal justice, business, or related discipline.
• Minimum 7+ years of experience in professional investigations involving economic or health insurance matters or related field.
• Prefers 2-3 years experience managing staff.
• Requires AHFI/CFE or other relevant professional certification (e.g. Masters degree may be considered).

Responsibilities

• Provide general supervision to investigators with their case management and prioritization.
• Guide investigators in the preparation and documentation of fraud cases for referral to the appropriate agencies and for potential prosecution or civil litigation.
• Coordinates with SIU Manager or Director regarding approval of settlement terms related to health care fraud investigations.
• Establishes and maintains liaison with local state and federal law enforcement as well as regulatory agencies.
• Serves as Company's representative in testifying in legal proceedings as required in fraud cases.
• Represents the Company in conducting settlement negotiations with attorneys and/or other responsible parties.
• Providers litigation support to the Legal Division's Litigation team as well as outside counsel hired to pursue civil litigation on behalf of Horizon BCBSNJ.
• Provides subject matter expertise to all SIU staff and other areas of the company.
• Represents the SIU on cross-divisional standing or temporary committees.
• Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administer salaries for the staff.

Skills

Investigations

Staff leadership

Negotiation

Interviewing

Communication

Analytical skills

Education

BA in criminal justice or related discipline

AHFI/CFE certification

Master's degree may be considered

Tools

MS Office

Excel

Access

Job description

About the Role

This position manages an SIU Team within the Special Investigations Unit, specifically for our Federal Employee Program. Supervises a team of investigators charged with detecting fraudulent activities by subscribers, providers, groups, and other parties.

What You’ll Do

• Provide general supervision to investigators with their case management/prioritization and provide guidance regarding the most efficient and effective method of investigation appropriate for each individual case.
• Guide investigators in the preparation and documentation of fraud cases for referral to the appropriate agencies and for potential prosecution or civil litigation.
• Coordinates with SIU Manager or Director regarding approval of settlement terms related to health care fraud investigations.
• Establishes and maintains liaison with local state and federal law enforcement as well as regulatory agencies (e.g. DOBI, MFD).
• Serves as Company's representative in testifying in legal proceedings as required in fraud cases.
• Represents the Company in conducting settlement negotiations with attorneys and/or other responsible parties (representing providers, enrolled groups and individual subscribers).
• Providers litigation support to the Legal Division's Litigation team as well as outside counsel hired to pursue civil litigation on behalf of Horizon BCBSNJ.
• Provides subject matter expertise to all SIU staff and other areas of the company.
• Represents the SIU on cross-divisional standing or temporary committees. (e.g. Payment Integrity, Provider Credentialing).
• Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.

What You Bring

Education/Experience

Requires BA in criminal justice, business, or related discipline. Requires a minimum of 7+ years of experience in professional investigations involving economic or health insurance related matters or relevant field. Prefers 2-3 yrs experience managing staff.

Licensing, certifications, and registrations

Requires AHFI CFE, CPC or other relevant professional certification (e.g. In lieu of certification; Masters degree may be considered.) Licensing in a medical field a plus.

Knowledge

Requires in depth knowledge of health insurance operations (i.e. claims, enrollment, underwriting, etc.). Requires working knowledge of NJ Criminal and Civil Law relative to health insurance fraud. Requires Knowledge of applicable fraud statutes: local, state, federal Requires working knowledge of investigative process. Requires demonstrated ability in MS Office applications, in particular Excel and Access. Requires the ability to create and interpret databases.

Skills and Abilities

Requires excellent verbal and written communication skills. Requires the ability to effectively handle and defuse confrontational situations. Requires strong organizational skills. Requires demonstrated ability to conduct interviews/interrogations. Requires excellent negotiation skills. Requires proven analytical and research skills.

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

$87,300 - $119,070

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.

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 or 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.

Mission

We empower our members to achieve their best health.

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.