Horizon Blue Cross Blue Shield of NJ Investigator II in Trenton, New Jersey

Investigator II

Job ID: PJE052018-11556

Description:

Job Summary:

This position is accountable 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

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.

Knowledge:

  • 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

Education/Experience:

  • Bachelor’s Degree

  • Associates Degree with 3-5 years health insurance experience specific to SIU or Audit/Quality operations.

  • May consider individual with health insurance SIU related experience.

  • Travel as needed to support investigative activity within Company's service area

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.

Requirements:

EducationAssociates

Job LevelIndividual Contributor

ExpertiseSecurity & Administration

Job TypeFull Time

LocationTrenton, NJ

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.