Investigator II

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

1d•$63,000 - $84,420

About The Position

This position conducts analytical and investigative activities, both internal and external, involving claims, enrollment, accounting, and other operations. It detects, receives, and reviews suspected fraud and completes cases with the information and analysis needed for resolution, as directed by the manager and approved guidelines. For the FEP line of business, the Investigator II follows applicable Federal Employee Health Benefits Carrier Letter procedures, investigates cases affecting FEP and FEP eligibility, maintains case information in the FEP SIU Tracking System, interfaces with the BCBSA FEP SIU Consultant, and handles fraud hotline calls affecting the FEP program. Travel is required as needed to support investigative activity within the Company’s service area. The role prepares fraud cases and evidence for potential prosecution or civil litigation, supports law enforcement proceedings, performs field investigations, coordinates with law enforcement, state agencies, and claims stakeholders, and represents the Company in complex settlement negotiations and legal proceedings. The salary range is $63,000–$84,420. Horizon offers a comprehensive compensation and benefits package. Employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Requirements

High school diploma or GED.
At least 2 years of claims, customer service, or relevant law enforcement experience.
Basic knowledge of health insurance operations, including claims, enrollment, and underwriting.
Basic knowledge of SIU health insurance operations.
Excellent verbal and written communication skills.
Ability to effectively handle confrontational situations.
Demonstrated ability in Microsoft Office applications, particularly Excel and Access.
Strong organizational skills.
Must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.
Travel as needed to support investigative activity within the Company’s service area.

Nice To Haves

ITS/Blue Card knowledge.

Responsibilities

Prepare and document fraud cases, assembling evidence for potential prosecution or civil litigation.
Provide evidence and/or testify in cases where law enforcement agencies pursue prosecution.
Personally handle field investigation work and coordinate efforts with law enforcement, state agencies, and claims stakeholders.
Represent the Company in complex settlement negotiations with attorneys or other responsible parties representing providers, enrolled groups, and individual subscribers.
Represent the Company in testifying in legal proceedings as required in fraud cases.
Follow established procedures and guidelines outlined in the latest Federal Employee Health Benefits (FEHB) Carrier Letter.
Investigate cases that impact the FEP line of business and handle investigations regarding FEP eligibility.
Update and track case activity, subpoenas, financial information, audits, referrals, settlements, and convictions affecting FEP in the FEP SIU Tracking System (FSTS).
Interface with the BCBSA FEP SIU Consultant.
Manage calls from the Fraud hotline that impact the FEP program.