Investigator III

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.

• Detects fraudlent activities by subscribers, providers, groups, employees and other parties.
• Decides the most efficient and effective method of investigation appropriate for each individual case.
• Prepares and documents fraud cases, assembling evidence for potential prosecution or civil litigation.
• Represents the company in conducting settlement negotiations with attorneys and or other responsible parties representing providers, enrolled groups and individual subscribers.
• Serves as the Company-s representative in testifying in legal proceedings as required by fraud cases.
• Provides subject matter expertise to SIU staff
• Supports Legal Division-s litigation unit on special projects/assignments.

Indivisdual Contributor Competencies

• Communicate
• Customer Focus
• Accountable
• Learn

• Requires 7 plus years prior professional investigation experience involving economic or insurance related matters.

Additional licensing, certifications, registrations

• Requires AHFI CFE, CPC certifications
• Licensing in a medical field a plus.

Knowledge

• Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel ,Access ) and; should be knowledgeable in the use of intranet and internet applications.
• Requires in depth knowledge of health insurance operations (i.e. claims, enrollment, underwriting, etc.)
• Requires working knowledge of NJ criminal and Civil Law relative to health insurance fraud.
• Requires knowledge of and working experience of investigative process.

Skills and Abilities

• Proven analytical, research and problem solving skills a must.
• Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.
• Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
• Requires the ability to effectively handle and defuse confrontational situations
• Requires strong organizational skills
• Requires demonstrated ability to conduct interviews/interrogations.
• Requires the ability to create and interpret databases.

Scope of Accountabilities

• Travel as needed to support investigation activity within Company-s service activities.

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Salary Range:

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

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. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.