Investigator II
纽约州的蓝十字绿盾赋予我们的成员能力，以达到他们最好的健康.90多年来，我们一直是新泽西州的卫生解决方案领导者，推动了改善医疗保健质量，可负担性和会员体验的创新。我们的成员是我们的邻居，朋友和家庭。这就是这种理解驱使我们更好地为信任我们的人群服务和照顾3.5百万人。我们自豪的是我们在班级中最优秀的员工，并努力保持一个让他们壮成长的创新的和包容环境。当我们的员工尽最大努力成功时，公司就会取得成功。关于角色 该职位负责与索赔，注册，会计和其他活动有关的分析和调查活动 （外部和内部）,以检测，接收和审查涉嫌欺诈的行为，并完成案件的所有信息和分析来解决问题，如经理和先前批准的指导方针所指示。你将做什么 · 准备和记录欺诈案例，收集可能的起诉或民事诉讼证据。· 在执法机构追求起诉的情况下提供证据和/或作证。·个人处理实地调查工作；并协调与执法国家机构和索赔利益相关者的工作。· 代表公司在与律师和/或其他负责人 （代表提供商，注册群体和单个订户）进行复杂且可能耗资数百万美元的和解谈判中。· 在欺诈案件中作为公司代表作证。· 对于成功执行至关重要的额外个人和专业属性.FEP LOB 的调查员 II 将完成上述任务，除了以下内容之外：·按照最新联邦雇员健康福利承运者信 (FEHB) 中所规定的程序和指导方针。· 调查影响 FEP LOB 的案件，以及处理有关 FEP 资格的所有调查。·更新和跟踪 FEPSIU 追踪系统 (FSTS),以事件活动，提前召唤，财务信息，审计，转让，和解和对影响 FEP 案例的判决进行调查。· 与 BCSA FEPSIU 顾问互通。·管理所有影响 FEP 计划的欺诈热线电话。你带来的教育/经验：· 高中文凭/GED r
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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.
About the Role
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, as the manager and prior approved guidelines may direct.What You'll Do
- 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.
- Additional personal and professional attributes that are critical to successful performance.
The Investigator II for the FEP LOB will complete the tasks listed above in addition to the following:
- Follow established procedures and guidelines outlined in the latest Federal Employee Health Benefits (FEHB) Carrier Letter.
- Investigate cases that impact the FEP LOB, as well as handling all investigations regarding FEP eligibility.
- Updating and tracking the FEP SIU Tracking System (FSTS) with case activity, subpoenas, financial information, audits, referrals, settlements and convictions of cases impacting the FEP.
- Interfaces with the BCBSA FEP SIU Consultant.
- Manages all calls from the Fraud hotline that impact the FEP program.
What You Bring
Education/Experience:
- High School Diploma/GED required.
- Minimum 2 yrs claims, customer service or relevant law enforcement experience required.
- ITS/Blue Card knowledge preferred
Knowledge:
- Requires basic knowledge of health insurance operations (i.e. claims, enrollment, underwriting, etc.).
- Requires basic knowledge of SIU health insurance operations.
Skills and Abilities:
- 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.
Travel:
· Travel as needed to support investigative activity within Company's service area.
Why Horizon?
At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you!
Salary Range:
$63,000 - $84,420This 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:
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. 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.
Originally posted on Himalayas