Supv, FEP Investigations
About The Position
This position manages a Special Investigations Unit (SIU) team focused on the Federal Employee Program and supervises investigators who detect fraudulent activities by subscribers, providers, groups, and other parties. The role provides investigative guidance, supports preparation and referral of fraud cases, coordinates settlement approvals, and works with law enforcement, regulatory agencies, the Legal Division, and outside counsel. It also represents the company in legal proceedings and settlement negotiations, provides subject matter expertise, participates in cross-divisional committees, and manages staff development and performance.
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-related 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 relevant 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.
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 efficient and effective investigative approaches.
- Guide investigators in preparing and documenting fraud cases for referral to appropriate agencies and potential 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.
- Conduct settlement negotiations with attorneys and other parties representing providers, enrolled groups, and individual subscribers.
- Provide litigation support to the Legal Division's Litigation team and outside counsel pursuing civil litigation on behalf of 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; develop and monitor goals; conduct annual performance reviews; and administer staff salaries.
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.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
