Investigator II

Horizon Healthcare Services • Newark, NJ

2d

About The Position

This position conducts analytical and investigative activities, both external and internal, related to 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.

The Investigator II prepares fraud cases and documents evidence for potential prosecution or civil litigation, provides evidence or testimony when law enforcement pursues prosecution, conducts field investigations, and coordinates with law enforcement, state agencies, and claims stakeholders. The role also represents the Company in complex settlement negotiations and legal proceedings involving fraud cases.

For the Federal Employee Program (FEP) line of business, the Investigator II follows applicable FEHB Carrier Letter procedures, investigates FEP cases and eligibility matters, maintains case information in the FEP SIU Tracking System, interfaces with the BCBSA FEP SIU Consultant, and handles FEP-related fraud hotline calls. Travel may be needed to support investigative activity within the Company's service area. 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.

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 with law enforcement, state agencies, and claims stakeholders.
• Represent the Company in complex settlement negotiations with attorneys and other responsible parties, including matters involving potentially multi-million dollar settlements.
• Testify as the Company's representative in legal proceedings as required in fraud cases.
• Follow established procedures and guidelines outlined in the latest Federal Employee Health Benefits (FEHB) Carrier Letter for FEP work.
• 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 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.
• Travel as needed to support investigative activity within the Company's service area.

Benefits

• Comprehensive health benefits, including medical, dental, and vision coverage.
• Retirement plans.
• Generous paid time off.
• Incentive plans.
• Wellness programs.
• Paid volunteer time off.
• Tuition reimbursement.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED