Investigator II

Horizon Blue Cross Blue Shield of New Jersey•Newark, NJ

About The Position

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, as the manager and prior approved guidelines may direct. Additional personal and professional attributes that are critical to successful performance: 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. 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.

Requirements

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

Nice To Haves

ITS/Blue Card knowledge preferred

Responsibilities

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.