Investigator II

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

1d•$63,000 - $84,420

About The Position

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. This is a senior level investigator expected to conduct and resolve investigations and manage their case load with limited management/supervisor oversight.

Requirements

Bachelors Degree Required
Minimum 2 yrs claims, customer service or relevant law enforcement experience required.
Requires in depth knowledge of health insurance operations (i.e. claims, enrollment, underwriting, etc.)
Requires excellent verbal and written communication skills.
Requires the ability to effectively handle and defuse confrontational situations.
Requires demonstrated ability in MS Office applications, in particular Excel and Access.
Requires strong organizational skills.
Requires demonstrated ability to conduct interviews/interrogations.
Requires the ability to create and interpret databases using multiple software applications.

Nice To Haves

ITS/Blue Card knowledge preferred
AHFI, CFE, or CPC certifications preferred
Prefers licensing in medical field.
Will consider advanced degree in lieu of certification.
Prefers working knowledge of NJ Criminal and Civil Law relative to health insurance fraud.
Prefers working knowledge of investigative process

Responsibilities

Detects fraudulent activities by subscribers, providers, groups, employees and other parties.
Decides the most efficient and effective method of investigation appropriate for each individual case.
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.
Up to date and Knowledgeable about all applicable fraud statutes; Local, state and federal to ensure duties and assignments are carried out within the requirement of applicable law and local office expectations.