Supv, FEP Investigations

Horizon Healthcare Services•Newark, NJ

About The Position

This position manages a Special Investigations Unit (SIU) team dedicated to the Federal Employee Program. The supervisor oversees investigators who detect fraudulent activities involving subscribers, providers, groups, and other parties. The role provides investigative direction, supports referrals and litigation, coordinates with law enforcement and regulatory agencies, and represents the Company in legal proceedings and settlement negotiations. It also provides subject matter expertise across the organization and manages staff development, goals, performance reviews, and salaries.

Requirements

Bachelor's degree in criminal justice, business, or a related discipline.
At least 7 years of experience in professional investigations involving economic or health insurance matters, or a relevant field.
AHFI, CFE, CPC, or another relevant professional certification; a master's degree may be considered in lieu of certification.
In-depth knowledge of health insurance operations, including claims, enrollment, and underwriting.
Working knowledge of New Jersey criminal and civil law related to health insurance fraud.
Knowledge of applicable local, state, and federal fraud statutes.
Working knowledge of the investigative process.
Demonstrated ability with Microsoft Office applications, particularly Excel and Access.
Ability to create and interpret databases.
Excellent verbal and written communication skills.
Ability to effectively handle and defuse confrontational situations.
Strong organizational skills.
Demonstrated ability to conduct interviews and interrogations.
Excellent negotiation skills.
Proven analytical and research skills.
Must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Nice To Haves

Two to three years of experience managing staff.
Licensing in a medical field.

Responsibilities

Supervise investigators in case management and prioritization, and guide them on effective investigation methods for individual cases.
Guide investigators in preparing and documenting fraud cases for referral to appropriate agencies and possible prosecution or civil litigation.
Coordinate with the SIU Manager or Director to obtain approval of settlement terms related to health care fraud investigations.
Establish and maintain relationships with local, state, and federal law enforcement and regulatory agencies, including DOBI and MFD.
Represent the Company and testify in legal proceedings as required in fraud cases.
Represent the Company in settlement negotiations with attorneys and other responsible parties representing providers, enrolled groups, and individual subscribers.
Provide litigation support to the Legal Division's Litigation team and outside counsel pursuing civil litigation for Horizon BCBSNJ.
Provide subject matter expertise to SIU staff and other areas of the Company.
Represent the SIU on cross-divisional standing or temporary committees, such as Payment Integrity and Provider Credentialing.
Manage, develop, and train staff; establish and monitor goals; conduct annual performance reviews; and administer staff salaries.