Investigator III

Horizon Blue Cross Blue Shield of New Jersey • Newark, NJ • 3w ago

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey's health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.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.1. Detects fraudulent activities by subscribers, providers, groups, employees and other parties.2. Decides the most efficient and effective method of investigation appropriate for each individual case.3. Prepares and documents fraud cases, assembling evidence for potential prosecution or civil litigation.4. Provides evidence and/or testifies in cases where law enforcement agencies pursue prosecution.5. Personally handles field investigation work; and coordinates efforts with law enforcement state agnecies and claims stakeholders.6. 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).7. Serves as Company's representative in testifying in legal proceedings as required in fraud cases.8. 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.9. Additional personal and professional attributes that are critical to successful performance:Building PartnershipsCoachingManaging ConflictNegotiation Work StandardsEducation/Experience:- Bachelors Degree Required.- 5 years prior professional investigations experience involving economic or health insurance related matters required- May consider individual with health insurance SIU related experienceAdditional licensing, certifications, registrations:Prefers licensing in medical field.Knowledge:Requires in depth knowledge of health insurance operations (i.e. claims, enrollment, underwriting, etc.)Prefers working knowledge of NJ Criminal and Civil Law relative to health insurance fraud.Prefers working knowledge of investigative processSkills and Abilities: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.Travel % (If Applicable):Travel as needed to support investigative activity within Company's service areaScope of Accountabilities:- Supervise staff of- Annual new business goals were usually in excess of $- Operating budget of- Client revenue responsibility of or more- Claims approval authority:- Maintain minimum quality scores ofHorizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

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