Healthcare Investigator

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. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. 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.

Prepares and documents fraud cases, assembling evidence for potential prosecution or civil litigation.

Personally handles field investigation work; and coordinates efforts with law enforcement state agencies and claims stakeholders.

Serves as Company's representative in testifying in legal proceedings as required in fraud cases.

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.

Additional personal and professional attributes that are critical to successful performance.

High School Diploma / GED Required

Minimum 2 yrs claims, customer service or relevant law enforcement experience required.

Additional licensing, certifications, registrations:

Prefers licensing in medical field.

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.

Requires demonstrated ability in MS Office applications, in particular Excel and Access.

Requires the ability to create and interpret databases using multiple software applications.

We believe that when our people thrive, our communities do too. 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. Comprehensive health benefits (Medical/Dental/Vision)

Retirement Plans

Tuition Reimbursement

Horizon Blue Cross Blue Shield of New Jersey employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. 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.