Investigator II

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

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, as the manager and prior approved guidelines may direct.

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.
Follow established procedures and guidelines outlined in the latest Federal Employee Health Benefits (FEHB) Carrier Letter.
Investigate cases that impact the FEP LOB, as well as handling all investigations regarding FEP eligibility.
Updating and tracking the FEP SIU Tracking System (FSTS) with case activity, subpoenas, financial information, audits, referrals, settlements and convictions of cases impacting the FEP.
Interfaces with the BCBSA FEP SIU Consultant.
Manages all calls from the Fraud hotline that impact the FEP program.