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Horizon Connect @ Wall BCBSNJ
HealthcareHealthcare Insurance
Horizon Connect @ Wall BCBSNJ appears to represent a local program or office associated with Horizon Blue Cross Blue Shield of New Jersey. Its connection is to the healthcare insurance sector, with an apparent focus on local outreach and engagement involving members and healthcare providers in the Wall, New Jersey area. Available public information is limited, so the profile reflects the affiliation indicated by the organization’s name rather than a broader standalone company description.
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Investigator II, Health Insurance Fraud

Investigate suspected health insurance fraud, including claims and Federal Employee Program eligibility cases, for Horizon Blue Cross Blue Shield of New Jersey. Build case records, coordinate with law enforcement and stakeholders, and support legal proceedings.

USUnited StatesCTConnecticutNJNew JerseyNYNew YorkPAPennsylvania
$63,000 – $84,420 / year
RemoteFull-timeJuniorMiddleNo degree requiredEnglish RequiredGeneralInvestigator

Description

  • Review claims, enrollment, accounting, and operational activity to identify and investigate suspected fraud.
  • Prepare fraud case files and assemble evidence for possible criminal prosecution or civil litigation.
  • Provide evidence and testify when law enforcement agencies pursue prosecution.
  • Conduct field investigations and coordinate with law enforcement, state agencies, and claims stakeholders.
  • Represent the company in complex settlement negotiations with attorneys and other responsible parties.
  • Testify in fraud-related legal proceedings as needed.
  • Follow the latest Federal Employee Health Benefits Carrier Letter procedures and guidelines.
  • Investigate Federal Employee Program cases, including eligibility matters.
  • Maintain the FEP SIU Tracking System with case activity, subpoenas, financial details, audits, referrals, settlements, and convictions.
  • Liaise with the BCBSA FEP SIU Consultant.
  • Handle hotline calls concerning fraud in the FEP program.

Requirements

  • A high school diploma or GED is required.
  • At least two years of experience in claims, customer service, or relevant law enforcement is required.
  • Knowledge of ITS or Blue Card is preferred.
  • Basic knowledge of health insurance operations, such as claims, enrollment, and underwriting.
  • Basic knowledge of special investigation unit operations in health insurance.
  • Strong verbal and written communication skills.
  • Ability to manage confrontational situations effectively.
  • Proficiency with Microsoft Office applications, especially Excel and Access.
  • Strong organizational abilities.
  • Willingness to travel as needed for investigations within the company’s service area.
  • Must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Benefits

  • Medical, dental, and vision coverage.
  • Retirement plans.
  • Generous paid time off.
  • Incentive plans.
  • Wellness programs.
  • Paid volunteer time off.
  • Tuition reimbursement.

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