[Hiring] Supervisor, FEP Investigations @Horizon Blue Cross Blue Shield of New Jersey

Role Description

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.
• Coordinate with SIU Manager or Director regarding approval of settlement terms related to health care fraud investigations.
• Establish and maintain liaison with local state and federal law enforcement as well as regulatory agencies (e.g. DOBI, MFD).
• Serve as Company's representative in testifying in legal proceedings as required in fraud cases.
• Represent the Company in conducting settlement negotiations with attorneys and/or other responsible parties (representing providers, enrolled groups and individual subscribers).
• Provide litigation support to the Legal Division's Litigation team as well as outside counsel hired to pursue civil litigation on behalf of Horizon BCBSNJ.
• Provide subject matter expertise to all SIU staff and other areas of the company.
• Represent 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 administer salaries for the staff.

Qualifications

• 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.
• Prefers 2-3 years experience managing staff.
• 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.

Requirements

• 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.

Benefits

• Comprehensive health benefits (Medical/Dental/Vision)
• Retirement Plans
• Generous PTO
• Incentive Plans
• Wellness Programs
• Paid Volunteer Time Off
• Tuition Reimbursement

Salary Range

$87,300 - $119,070

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.