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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 manages an SIU Team within the Special Investigations Unit, specifically for our Federal Employee Program. Supervises a team of investigators charged with detecting fraudulent activities by subscribers, providers, groups, and other parties. What You'll Do
Provide general supervision to investigators with their case management/prioritization and provide guidance regarding the most efficient and effective method of investigation appropriate for each individual case.
Guide investigators in the preparation and documentation of fraud cases for referral to the appropriate agencies and for potential prosecution or civil litigation.
Coordinates with SIU Manager or Director regarding approval of settlement terms related to health care fraud investigations.
Establishes and maintains liaison with local state and federal law enforcement as well as regulatory agencies (e.g. DOBI, MFD).
Serves as Company's representative in testifying in legal proceedings as required in fraud cases.
Represents the Company in conducting settlement negotiations with attorneys and/or other responsible parties (representing providers, enrolled groups and individual subscribers).
Providers litigation support to the Legal Division's Litigation team as well as outside counsel hired to pursue civil litigation on behalf of Horizon BCBSNJ.
Provides subject matter expertise to all SIU staff and other areas of the company.
Represents the SIU on cross-divisional standing or temporary committees. (e.g. Payment Integrity, Provider Credentialing).
Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.
Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.
What You Bring
Education/Experience:
Requires BA in criminal justice, business, or related discipline.
Requires a minimum of 7+ years of experience in professional investigations involving economic or health insurance related matters or relevant field.
Requires AHFI CFE, CPC or other relevant professional certification (e.g. In lieu of certification; Masters degree may be considered.) Licensing in a medical field a plus.
Knowledge:
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 applicable fraud statutes: local, state, federal Requires working knowledge of investigative process.
Requires demonstrated ability in MS Office applications, in particular Excel and Access.
Requires the ability to create and interpret databases.
Skills and Abilities:
Requires excellent verbal and written communication skills.
Requires the ability to effectively handle and defuse confrontational situations.
Requires strong organizational skills.
Requires demonstrated ability to conduct interviews/interrogations.
Requires excellent negotiation skills.
Requires proven analytical and research skills.
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:
$87,300 - $119,070 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:
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.
